Provider Demographics
NPI:1497926687
Name:CADDY, GLENN ROSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ROSS
Last Name:CADDY
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 1:3101 NORTH FEDERAL HIGHWAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306
Mailing Address - Country:US
Mailing Address - Phone:954-565-8850
Mailing Address - Fax:954-565-9860
Practice Address - Street 1:3101 NORTH FEDERAL HIGHWAY
Practice Address - Street 2:SUITE 301
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306
Practice Address - Country:US
Practice Address - Phone:954-565-8850
Practice Address - Fax:954-565-9860
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2093103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical