Provider Demographics
NPI:1275680027
Name:BANNISTER, GLEN C JR (EDD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:C
Last Name:BANNISTER
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 LOMAC ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2817
Mailing Address - Country:US
Mailing Address - Phone:334-277-5956
Mailing Address - Fax:
Practice Address - Street 1:4216 LOMAC ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2817
Practice Address - Country:US
Practice Address - Phone:334-277-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL125103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-70696Medicare UPIN