Provider Demographics
NPI:1437379229
Name:MOMROW, EDWARD GLENN (THD PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GLENN
Last Name:MOMROW
Suffix:
Gender:M
Credentials:THD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 SARATOGA AVE
Mailing Address - Street 2:#104
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129
Mailing Address - Country:US
Mailing Address - Phone:408-249-8313
Mailing Address - Fax:408-867-4044
Practice Address - Street 1:940 SARATOGA AVE
Practice Address - Street 2:#104
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129
Practice Address - Country:US
Practice Address - Phone:408-249-8313
Practice Address - Fax:408-867-4044
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM01888101Y00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist