Basic Information
| Provider Information | |||||||||
| NPI: | 1689690307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CURTISS | ||||||||
| FirstName: | GLENN | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23933 FOREST VIEW DR | ||||||||
| Address2: | |||||||||
| City: | LAND O LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346394849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139966600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
| Address2: | J. A. HALEY VAMC (116B) | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336124745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139722000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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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 | 103G00000X | PY4068 | FL | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TR0400X | PY4068 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
No ID Information.