Basic Information
| Provider Information | |||||||||
| NPI: | 1801948195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | GLENNA | ||||||||
| MiddleName: | PATRICE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 WILSHIRE BLVD STE 704 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900574312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136392664 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 WILSHIRE BLVD | ||||||||
| Address2: | STE 704 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900574303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136392664 | ||||||||
| FaxNumber: | 2133891987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 1041C0700X | 29867 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.