Provider Demographics
NPI:1992890081
Name:DAVIDSON, GLENN S JR (PHD, HSPP)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:S
Last Name:DAVIDSON
Suffix:JR
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2265
Mailing Address - Country:US
Mailing Address - Phone:765-282-4317
Mailing Address - Fax:765-282-4362
Practice Address - Street 1:1901 W ROYALE DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2265
Practice Address - Country:US
Practice Address - Phone:765-282-4317
Practice Address - Fax:765-282-4362
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010351A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical