Provider Demographics
NPI:1093082000
Name:PETERS, GLENN ALAN (MS,NCC,LPC-IT,SAC-IT)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ALAN
Last Name:PETERS
Suffix:
Gender:M
Credentials:MS,NCC,LPC-IT,SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 W LISBON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2116
Mailing Address - Country:US
Mailing Address - Phone:414-871-9111
Mailing Address - Fax:
Practice Address - Street 1:6040 W LISBON AVE STE 102
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI621-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional