=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508193491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLORY ANN PALECEK PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2009
-----------------------------------------------------
Last Update Date | 10/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 H AVE
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-519-2554
-----------------------------------------------------
Fax | 619-437-0225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 H AVE
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-519-2554
-----------------------------------------------------
Fax | 619-435-7717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | PSY7272
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY7272
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY7272
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------