Provider Demographics
NPI:1225079262
Name:GLENWOOD
Entity Type:Organization
Organization Name:GLENWOOD
Other - Org Name:CENTER FOR CHILD AND ADOLESCENT DEVELOPMENT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:D
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:YOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-795-3210
Mailing Address - Street 1:2361 FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1633
Mailing Address - Country:US
Mailing Address - Phone:334-262-5744
Mailing Address - Fax:334-262-5155
Practice Address - Street 1:2361 FAIRLANE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1633
Practice Address - Country:US
Practice Address - Phone:334-262-5744
Practice Address - Fax:334-262-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529925380Medicaid