Provider Demographics
NPI:1447380746
Name:CANTRELL, GLENNA P
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:P
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 5 BOX 20
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-9611
Mailing Address - Country:US
Mailing Address - Phone:276-935-1130
Mailing Address - Fax:276-935-1538
Practice Address - Street 1:RR 5 BOX 20
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-9611
Practice Address - Country:US
Practice Address - Phone:276-935-1130
Practice Address - Fax:276-935-1538
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7401121000Medicaid