Provider Demographics
NPI:1689085037
Name:GLEASON, CARRIE (LP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 TIENKEN CT STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4369
Mailing Address - Country:US
Mailing Address - Phone:248-854-5520
Mailing Address - Fax:
Practice Address - Street 1:1130 TIENKEN CT STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48306-4369
Practice Address - Country:US
Practice Address - Phone:248-854-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty