Provider Demographics
NPI:1376315200
Name:GLENN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GLENN
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 1:4775 STONY MESA CT
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-7426
Mailing Address - Country:US
Mailing Address - Phone:720-284-2485
Mailing Address - Fax:
Practice Address - Street 1:4775 STONY MESA CT
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-7426
Practice Address - Country:US
Practice Address - Phone:720-284-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019858101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional