Basic Information
| Provider Information | |||||||||
| NPI: | 1356470215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLADISH | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | DONALD | ||||||||
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| Credential: | MA, LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HAMPTON CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483074195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488530750 | ||||||||
| FaxNumber: | 2488530792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401009572 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |