Provider Demographics
NPI:1164570420
Name:MAARSE, GLENN JACOB (PHD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:JACOB
Last Name:MAARSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E EDGAR ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3132
Mailing Address - Country:US
Mailing Address - Phone:206-323-3243
Mailing Address - Fax:206-407-3243
Practice Address - Street 1:2811 E MADISON ST STE 205D
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4869
Practice Address - Country:US
Practice Address - Phone:206-323-3243
Practice Address - Fax:206-723-0420
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY2011103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA217000767Medicare ID - Type Unspecified