Basic Information
| Provider Information | |||||||||
| NPI: | 1881029288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | SW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1610 CENTER ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514324560 | ||||||||
| FaxNumber: | 2514329013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 CENTER ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514324560 | ||||||||
| FaxNumber: | 2514329013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2013 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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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 | 104100000X | 1914G | AL | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.