Provider Demographics
NPI:1215120134
Name:MATHEWS, GLENN MOORE (LPC, LMFT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:MOORE
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-1826
Mailing Address - Country:US
Mailing Address - Phone:540-731-0838
Mailing Address - Fax:540-731-3375
Practice Address - Street 1:600 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1826
Practice Address - Country:US
Practice Address - Phone:540-731-0838
Practice Address - Fax:540-731-3375
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002141101YP2500X
VA50106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist