Provider Demographics
NPI:1073941712
Name:GLENN, CONNIE B
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:B
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 ACKERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-4426
Mailing Address - Country:US
Mailing Address - Phone:702-612-6787
Mailing Address - Fax:702-655-0062
Practice Address - Street 1:8800 ACKERMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89143-4426
Practice Address - Country:US
Practice Address - Phone:702-612-6787
Practice Address - Fax:702-655-0062
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant