Provider Demographics
NPI:1396994984
Name:GLENN, MARY DELORES (LPC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DELORES
Last Name:GLENN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2516 OAKLAND BLVD.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103
Mailing Address - Country:US
Mailing Address - Phone:817-535-6300
Mailing Address - Fax:817-535-4100
Practice Address - Street 1:2516 OAKLAND BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3201
Practice Address - Country:US
Practice Address - Phone:817-535-6300
Practice Address - Fax:817-535-4100
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX600085101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional