Provider Demographics
NPI:1083967632
Name:SCOTT, GLENN CALVIN JR
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:CALVIN
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8692 9TH ST UNIT 64
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0812
Mailing Address - Country:US
Mailing Address - Phone:951-849-5322
Mailing Address - Fax:
Practice Address - Street 1:6600 JURUPA AVE STE 103
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-1041
Practice Address - Country:US
Practice Address - Phone:951-840-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical