Provider Demographics
NPI:1679618391
Name:GLEASON, FAWN MARIE (MFT-INTERN)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:MARIE
Last Name:GLEASON
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 FOLSOM BLVD APT 422
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-5053
Mailing Address - Country:US
Mailing Address - Phone:916-854-4552
Mailing Address - Fax:916-854-4556
Practice Address - Street 1:9261 FOLSOM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2559
Practice Address - Country:US
Practice Address - Phone:916-854-4552
Practice Address - Fax:916-854-4556
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52905106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist