Provider Demographics
NPI:1215226055
Name:HAVEA, GLENN SAULALA
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:SAULALA
Last Name:HAVEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 NORTH 200 WEST, SUITE 300
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:
Practice Address - Street 1:720 NORTH 200 WEST, SUITE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2084P0800X(MD,DO)OtherBEHAVIORA HEALTH & SOCIAL SERVICE PROVIDERS