Provider Demographics
NPI:1467976068
Name:BARRON, GLENN W
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:W
Last Name:BARRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 MIRACLE STRIP PKWY SW STE B3
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5200
Mailing Address - Country:US
Mailing Address - Phone:850-862-3772
Mailing Address - Fax:
Practice Address - Street 1:348 MIRACLE STRIP PKWY SW STE B3
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5200
Practice Address - Country:US
Practice Address - Phone:850-862-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15375101YM0800X
FLIMT2617106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health