Provider Demographics
NPI:1386202042
Name:MALONEY, GLENN EMERY (LICSW, LADC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EMERY
Last Name:MALONEY
Suffix:
Gender:M
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 N 3RD AVE W STE 310
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1614
Mailing Address - Country:US
Mailing Address - Phone:218-740-2349
Mailing Address - Fax:
Practice Address - Street 1:5 N 3RD AVE W STE 310
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1614
Practice Address - Country:US
Practice Address - Phone:218-740-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN257141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical