Provider Demographics
NPI:1104471226
Name:GLENN, ANDREA LOUIISE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LOUIISE
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E MUIR AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91 N SAGINAW ST STE 101
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2165
Practice Address - Country:US
Practice Address - Phone:248-254-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician