Provider Demographics
NPI:1063776862
Name:GLISSMEYER, DEVAN G (PHD)
Entity type:Individual
Prefix:DR
First Name:DEVAN
Middle Name:G
Last Name:GLISSMEYER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84021
Mailing Address - Country:US
Mailing Address - Phone:435-738-2040
Mailing Address - Fax:
Practice Address - Street 1:382 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84021
Practice Address - Country:US
Practice Address - Phone:435-738-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4989891-3902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health