Provider Demographics
NPI:1073621546
Name:PERRY, GLENN ALAN (PHD, MFT)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ALAN
Last Name:PERRY
Suffix:
Gender:M
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 QUIETWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1338
Mailing Address - Country:US
Mailing Address - Phone:415-479-5812
Mailing Address - Fax:
Practice Address - Street 1:360 QUIETWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1338
Practice Address - Country:US
Practice Address - Phone:415-479-5812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 14207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist