Provider Demographics
NPI:1104993153
Name:SALLOWS, GLEN OWEN (PHD, BCBA-D)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:OWEN
Last Name:SALLOWS
Suffix:
Gender:M
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1210 FOURIER DRIVE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1969
Mailing Address - Country:US
Mailing Address - Phone:608-662-9327
Mailing Address - Fax:608-662-9041
Practice Address - Street 1:1210 FOURIER DRIVE
Practice Address - Street 2:SUITE #100
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1969
Practice Address - Country:US
Practice Address - Phone:608-662-9327
Practice Address - Fax:608-662-9041
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI823057103T00000X
WI54-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104993153Medicaid
WI39020200Medicaid