Provider Demographics
NPI:1396273637
Name:GLENN, MISTY ANNE (CDPT)
Entity type:Individual
Prefix:MS
First Name:MISTY
Middle Name:ANNE
Last Name:GLENN
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:MISS
Other - First Name:MISTY
Other - Middle Name:ANNE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 NW CHEHALIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-740-9767
Mailing Address - Fax:360-740-5484
Practice Address - Street 1:121 NW CHEHALIS AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-740-9767
Practice Address - Fax:360-740-5484
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60701395101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)