Healthcare Provider Details

I. General information

NPI: 1922318211
Provider Name (Legal Business Name): COLLEEN MARIE GLEASON ED.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 JAMESTOWN RD
FARMVILLE VA
23901-3909
US

IV. Provider business mailing address

402 JAMESTOWN RD
FARMVILLE VA
23901-3909
US

V. Phone/Fax

Practice location:
  • Phone: 434-414-8302
  • Fax:
Mailing address:
  • Phone: 434-414-8302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberPGP0658289
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: