Provider Demographics
NPI:1063482297
Name:KNOWLTON, GLENN E (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:E
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 13TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-3468
Mailing Address - Country:US
Mailing Address - Phone:701-364-0060
Mailing Address - Fax:701-364-0065
Practice Address - Street 1:1401 13TH AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3468
Practice Address - Country:US
Practice Address - Phone:701-364-0060
Practice Address - Fax:701-364-0065
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21784OtherBLUECROSS/SHIELD -NO DAK
MN660352100Medicaid
475441026976OtherPREFERRED ONE
61-77289OtherMEDICA (UBH)
MN266S4KNOtherBLUE CROSS/SHIELD-MINNESO
HP22979OtherHEALTHPARTNERS
ND16921Medicaid
MN266S4KNOtherBLUE CROSS/SHIELD-MINNESO
R02272Medicare UPIN