Provider Demographics
NPI:1528085172
Name:WEIS, GLENNA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:GLENNA
Middle Name:MARIE
Last Name:WEIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WEST WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2096
Mailing Address - Country:US
Mailing Address - Phone:417-425-9100
Mailing Address - Fax:417-719-9002
Practice Address - Street 1:205 WEST WALNUT STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2096
Practice Address - Country:US
Practice Address - Phone:417-425-9100
Practice Address - Fax:417-719-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002030467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical