Provider Demographics
NPI:1912756024
Name:MULREADY, GLEN WILLIAM II
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:WILLIAM
Last Name:MULREADY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 W 77TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-2853
Mailing Address - Country:US
Mailing Address - Phone:918-998-5020
Mailing Address - Fax:
Practice Address - Street 1:614 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4059
Practice Address - Country:US
Practice Address - Phone:405-564-3408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health