Provider Demographics
NPI:1104080381
Name:GLANVILLE, ALISON LYNN (PSYD)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:LYNN
Last Name:GLANVILLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4909
Mailing Address - Country:US
Mailing Address - Phone:207-942-3816
Mailing Address - Fax:207-561-4725
Practice Address - Street 1:29 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4909
Practice Address - Country:US
Practice Address - Phone:207-942-3816
Practice Address - Fax:207-561-4725
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1272103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432786799Medicaid
ME001050401Medicare PIN