Basic Information
| Provider Information | |||||||||
| NPI: | 1750928859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | LICSW, PIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 GARY ANDERS RD | ||||||||
| Address2: | |||||||||
| City: | HARTSELLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356407307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563186300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1111 WAYNE RD NW STE 6 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358063573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562883333 | ||||||||
| FaxNumber: | 2562883334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2019 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4242C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.