Provider Demographics
NPI:1346919164
Name:GLENBOSKI, MELINDA MARIE
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIE
Last Name:GLENBOSKI
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 1:39 LAKEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3124
Mailing Address - Country:US
Mailing Address - Phone:707-774-9526
Mailing Address - Fax:
Practice Address - Street 1:39 LAKEVILLE ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3124
Practice Address - Country:US
Practice Address - Phone:707-774-9526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician