Provider Demographics
NPI:1376941120
Name:CARPENTER, GLEN ALAN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ALAN
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1352
Mailing Address - Country:US
Mailing Address - Phone:419-699-3357
Mailing Address - Fax:419-491-4886
Practice Address - Street 1:1544 S BYRNE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-3465
Practice Address - Country:US
Practice Address - Phone:419-509-3442
Practice Address - Fax:419-491-4886
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.13023111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical