Provider Demographics
NPI:1407558935
Name:GLENN, MALIK KADEEM
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:KADEEM
Last Name:GLENN
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 1:1514 SAINT ALBANS LN
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-2916
Mailing Address - Country:US
Mailing Address - Phone:716-510-1457
Mailing Address - Fax:
Practice Address - Street 1:1900 C ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON, DC
Practice Address - State:MD
Practice Address - Zip Code:20607
Practice Address - Country:US
Practice Address - Phone:202-388-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician