Provider Demographics
NPI:1043732209
Name:GLENN, CONNIE (MS, LMFT)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15010 AVENIDA MONTUOSA APT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-1459
Mailing Address - Country:US
Mailing Address - Phone:858-525-1934
Mailing Address - Fax:
Practice Address - Street 1:721 N VULCAN AVE STE 106-108
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2190
Practice Address - Country:US
Practice Address - Phone:760-942-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100516106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist