Provider Demographics
NPI:1114020153
Name:GLENN, KATHERINE HOWARD (PHD)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:HOWARD
Last Name:GLENN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603 B NEW GARDEN VILLAGE DR.
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410
Mailing Address - Country:US
Mailing Address - Phone:336-272-8090
Mailing Address - Fax:336-272-0094
Practice Address - Street 1:5603 B NEW GARDEN VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410
Practice Address - Country:US
Practice Address - Phone:336-272-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS650101YA0400X
NC704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102104Medicaid