Provider Demographics
NPI:1003939323
Name:DOHERTY, GLENNON CHARLES (MED, LPC)
Entity Type:Individual
Prefix:MR
First Name:GLENNON
Middle Name:CHARLES
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S CLAY AVE
Mailing Address - Street 2:APT. 3
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4215
Mailing Address - Country:US
Mailing Address - Phone:314-849-2989
Mailing Address - Fax:
Practice Address - Street 1:214 S CLAY AVE
Practice Address - Street 2:APT. 3
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4215
Practice Address - Country:US
Practice Address - Phone:314-849-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health