Provider Demographics
NPI:1356637318
Name:RATLIFF, GLENN W (MA)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:W
Last Name:RATLIFF
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:97 GREAT TEAYS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9816
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-201-5019
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV1016103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356637318Medicaid