=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124478490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL D GLEASON MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2016
-----------------------------------------------------
Last Update Date | 06/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 NORTH AVE
-----------------------------------------------------
City | PENN YAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14527-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-536-7447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 E LAKE RD UNIT 7C
-----------------------------------------------------
City | CANANDAIGUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14424-2353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-415-5465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------