Basic Information
Provider Information | |||||||||
NPI: | 1285696922 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VEENSTRA | ||||||||
FirstName: | GLENN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1010 N KANSAS | ||||||||
Address2: | SUITE #3049 | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672143199 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3162932647 | ||||||||
FaxNumber: | 3162931882 | ||||||||
Practice Location | |||||||||
Address1: | 7829 E ROCKHILL ST | ||||||||
Address2: | SUITE #105 | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672063920 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3162933850 | ||||||||
FaxNumber: | 3166836733 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 11/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0507 | KS | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 04414 | 01 | KS | BCBS | OTHER | 100237810A | 05 | KS |   | MEDICAID |