Basic Information
| Provider Information | |||||||||
| NPI: | 1598207847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN-LEWIS | ||||||||
| FirstName: | DELORES | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GLENN | ||||||||
| OtherFirstName: | DELORES | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4000 E CHARLESTON BLVD | ||||||||
| Address2: | 226 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891046659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029685071 | ||||||||
| FaxNumber: | 7029381497 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 E CHARLESTON BLVD | ||||||||
| Address2: | 226 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891046659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029685071 | ||||||||
| FaxNumber: | 7029381497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2016 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.