Provider Demographics
NPI:1154021384
Name:GLYNN, MAEGAN
Entity type:Individual
Prefix:
First Name:MAEGAN
Middle Name:
Last Name:GLYNN
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 1:825 GUM BRANCH RD STE 107
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6270
Mailing Address - Country:US
Mailing Address - Phone:910-353-0972
Mailing Address - Fax:910-353-1439
Practice Address - Street 1:918 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-7420
Practice Address - Country:US
Practice Address - Phone:910-353-0972
Practice Address - Fax:910-353-1439
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18604101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health