Basic Information
| Provider Information | |||||||||
| NPI: | 1063482297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOWLTON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 13TH AVE E | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580783468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013640060 | ||||||||
| FaxNumber: | 7013640065 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 13TH AVE E | ||||||||
| Address2: | |||||||||
| City: | WEST FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580783468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013640060 | ||||||||
| FaxNumber: | 7013640065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 01/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 210 | ND | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 21784 | 01 | ND | BLUECROSS/SHIELD -NO DAK | OTHER | 660352100 | 05 | MN | MEDICAID | 475441026976 | 01 | PREFERRED ONE | OTHER | 61-77289 | 01 | MEDICA (UBH) | OTHER | 266S4KN | 01 | MN | BLUE CROSS/SHIELD-MINNESO | OTHER | HP22979 | 01 | HEALTHPARTNERS | OTHER | 16921 | 05 | ND | MEDICAID |