Provider Demographics
NPI:1154929255
Name:TYSON, GLENN WILLIAM (LPC)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:WILLIAM
Last Name:TYSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10344 W 44TH AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2741
Mailing Address - Country:US
Mailing Address - Phone:973-647-5558
Mailing Address - Fax:
Practice Address - Street 1:8015 W ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3041
Practice Address - Country:US
Practice Address - Phone:720-767-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016334101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional