Provider Demographics
NPI:1497708465
Name:COLLET, GLENN MARK (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:MARK
Last Name:COLLET
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Gender:M
Credentials:PSYCHOLOGIST
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Mailing Address - Street 1:1212 SW LUTTRELL RD
Mailing Address - Street 2:STE F
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-4924
Mailing Address - Country:US
Mailing Address - Phone:816-229-4877
Mailing Address - Fax:816-229-4891
Practice Address - Street 1:1212 SW LUTTRELL RD
Practice Address - Street 2:STE F
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-4924
Practice Address - Country:US
Practice Address - Phone:816-229-4877
Practice Address - Fax:816-229-4891
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO00801103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0009903Medicare ID - Type Unspecified