Provider Demographics
NPI:1093884520
Name:URBAN, GLYNNIS PELLETT (CMHC)
Entity Type:Individual
Prefix:
First Name:GLYNNIS
Middle Name:PELLETT
Last Name:URBAN
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 W AZTEC BLVD
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1800
Mailing Address - Country:US
Mailing Address - Phone:505-419-9926
Mailing Address - Fax:
Practice Address - Street 1:1118 W AZTEC BLVD
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-1800
Practice Address - Country:US
Practice Address - Phone:505-334-3695
Practice Address - Fax:505-599-4388
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2292101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23930772Medicaid