Provider Demographics
NPI:1114321486
Name:GLENN, CEDRIC
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 E 72ND ST
Mailing Address - Street 2:1803
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5372
Mailing Address - Country:US
Mailing Address - Phone:813-388-3773
Mailing Address - Fax:
Practice Address - Street 1:1721 E 72ND ST
Practice Address - Street 2:1803
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5372
Practice Address - Country:US
Practice Address - Phone:813-388-3773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility