Basic Information
| Provider Information | |||||||||
| NPI: | 1023235843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | TORRE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 572 | ||||||||
| Address2: | |||||||||
| City: | EAST NORTHPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117310479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166163033 | ||||||||
| FaxNumber: | 5168738881 | ||||||||
| Practice Location | |||||||||
| Address1: | 448 LAKESHORE PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297304264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033289600 | ||||||||
| FaxNumber: | 8033297141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 303272 | NC | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 1041C0700X | 075195 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 3339 | 01 | SC | MEDICARE | OTHER | 1568476885 | 05 | SC | MEDICAID |