Provider Demographics
NPI:1699898304
Name:GLENN, RODNEY MAURICE (BA)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:MAURICE
Last Name:GLENN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 GARNET AVE
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:CA
Mailing Address - Zip Code:93560-6885
Mailing Address - Country:US
Mailing Address - Phone:661-510-2237
Mailing Address - Fax:
Practice Address - Street 1:921 W AVENUE J
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007473Medicaid
CACBSC297OtherLA DMH PROVIDER