Provider Demographics
NPI:1164581096
Name:WILLIAMS GLENN, KEENEYA H
Entity Type:Individual
Prefix:
First Name:KEENEYA
Middle Name:H
Last Name:WILLIAMS GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9934 W REEVES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28356-8714
Mailing Address - Country:US
Mailing Address - Phone:917-678-3593
Mailing Address - Fax:
Practice Address - Street 1:1301 FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-426-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0777931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical