Provider Demographics
NPI:1447580857
Name:PADDOCK, GLEN BENJAMIN (PHD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:BENJAMIN
Last Name:PADDOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16513 133RD PL SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-6968
Mailing Address - Country:US
Mailing Address - Phone:206-619-7734
Mailing Address - Fax:
Practice Address - Street 1:4007 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE F2
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4330
Practice Address - Country:US
Practice Address - Phone:253-565-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist