1700305315 NPI number — MS. HEATHER DENISE GLENN LPC INTERN, NCC, CRC

Table of content: MS. HEATHER DENISE GLENN LPC INTERN, NCC, CRC (NPI 1700305315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700305315 NPI number — MS. HEATHER DENISE GLENN LPC INTERN, NCC, CRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLENN
Provider First Name:
HEATHER
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC INTERN, NCC, CRC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700305315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 SW 105TH AVENUE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-435-7663
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6700 SW 105TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-435-7663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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