Provider Demographics
NPI:1417145822
Name:MINGLEDORFF, GLENA LEE (LPC)
Entity Type:Individual
Prefix:MS
First Name:GLENA
Middle Name:LEE
Last Name:MINGLEDORFF
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 TROTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5048
Mailing Address - Country:US
Mailing Address - Phone:931-381-7441
Mailing Address - Fax:
Practice Address - Street 1:5001 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5048
Practice Address - Country:US
Practice Address - Phone:931-381-7441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC412101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4071811OtherBC/BS