Basic Information
| Provider Information | |||||||||
| NPI: | 1457796369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | EVERETT | ||||||||
| MiddleName: | TETUSHI | ||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39500 STEVENSON PL STE 203 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945393103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109841654 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 39500 STEVENSON PL STE 203 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945393103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109841654 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 70294 | CA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.