Provider Demographics
NPI:1477148393
Name:BOU, GLENDALIE
Entity Type:Individual
Prefix:
First Name:GLENDALIE
Middle Name:
Last Name:BOU
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 1:133 OLD ENGLAND LOOP APT 133
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6570
Mailing Address - Country:US
Mailing Address - Phone:407-310-9870
Mailing Address - Fax:
Practice Address - Street 1:1150 S SEMORAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1424
Practice Address - Country:US
Practice Address - Phone:407-704-7811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health