Provider Demographics
NPI:1083985469
Name:GLENN, GROVER (LPC, LISAC, CPHQ)
Entity type:Individual
Prefix:
First Name:GROVER
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:LPC, LISAC, CPHQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-4730
Mailing Address - Country:US
Mailing Address - Phone:520-618-8622
Mailing Address - Fax:
Practice Address - Street 1:2700 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-4730
Practice Address - Country:US
Practice Address - Phone:520-618-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC11140101YP2500X
AZLISAC10259101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-11140OtherCOUNSELING LICENSE
AZLISAC-10259OtherSUBSTANCE ABUSE COUNSELING LICENSE