Basic Information
| Provider Information | |||||||||
| NPI: | 1912498890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | VIKEASHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 CRAWFORD ST STE 208 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770028941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137399725 | ||||||||
| FaxNumber: | 8662423803 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 CRAWFORD ST STE 208 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770028941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137399725 | ||||||||
| FaxNumber: | 8662423803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2018 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3612756 | 05 | TX | MEDICAID |