Provider Demographics
NPI:1144857467
Name:TANIMURA, GLENN M (AMFT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:TANIMURA
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1079 NOBLE LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-3128
Mailing Address - Country:US
Mailing Address - Phone:408-772-0953
Mailing Address - Fax:
Practice Address - Street 1:1079 NOBLE LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-3128
Practice Address - Country:US
Practice Address - Phone:408-772-0953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT97149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist