Provider Demographics
NPI:1104005693
Name:POWELL, GLEN VICTOR (MS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:VICTOR
Last Name:POWELL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 OLDE COLONIAL DR APT 6
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-4212
Mailing Address - Country:US
Mailing Address - Phone:978-273-8438
Mailing Address - Fax:
Practice Address - Street 1:100 ERDMAN WAY
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1804
Practice Address - Country:US
Practice Address - Phone:978-537-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health