Basic Information
| Provider Information | |||||||||
| NPI: | 1861810244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | GENEVRA | ||||||||
| MiddleName: | DIANA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2781 W RAMSEY | ||||||||
| Address2: | |||||||||
| City: | BANNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518493896 | ||||||||
| FaxNumber: | 9518490506 | ||||||||
| Practice Location | |||||||||
| Address1: | 2781 W RAMSEY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BANNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518493896 | ||||||||
| FaxNumber: | 9518490506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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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 | 101YA0400X | 11980613 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.