Provider Demographics
NPI:1437272945
Name:ALLY, GLENN A (PHD, MP)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:ALLY
Suffix:
Gender:M
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 HOSPITAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2852
Mailing Address - Country:US
Mailing Address - Phone:337-235-8304
Mailing Address - Fax:337-235-5924
Practice Address - Street 1:155 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-235-8304
Practice Address - Fax:337-235-5924
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA378MP103G00000X, 103TC0700X, 103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1969559Medicaid
LA56200Medicare ID - Type UnspecifiedPSYCHOLOGIST