Provider Demographics
NPI:1427152529
Name:SHEAN, GLENN D (LCP)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:SHEAN
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:VA
Mailing Address - Zip Code:23692-1069
Mailing Address - Country:US
Mailing Address - Phone:757-877-9140
Mailing Address - Fax:757-877-3925
Practice Address - Street 1:6515 GEORGE WASHINGTON MEM HWY
Practice Address - Street 2:STE 100
Practice Address - City:GRAFTON
Practice Address - State:VA
Practice Address - Zip Code:23692-2182
Practice Address - Country:US
Practice Address - Phone:757-877-9140
Practice Address - Fax:757-877-3925
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0107000605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
017162OtherANTHEM
VA7746563Medicaid
001979OtherVALUE OPTIONS