Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | PSY7272 | CA |
Y | 103G00000X | Clinical Psychologist | PSY7272 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY7272 | CA |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | PSY7272 | CA |
NPI | 1508193491 |
---|---|
Provider Name | Dr. Glory Ann Palecek |
First Address | Coronado, CA 92118-1222 |
Second Address | Coronado, CA 92118-1222 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2009 |
Last Update Date | 29/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1508193491 | TRICARE (01) | CA |