Provider Demographics
NPI:1508326265
Name:GLENN, O'NEIL CALVERT
Entity Type:Individual
Prefix:MR
First Name:O'NEIL
Middle Name:CALVERT
Last Name:GLENN
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 1:2447 EASTCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5915
Mailing Address - Country:US
Mailing Address - Phone:718-882-2111
Mailing Address - Fax:718-882-2117
Practice Address - Street 1:2447 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5915
Practice Address - Country:US
Practice Address - Phone:718-882-2111
Practice Address - Fax:718-882-2117
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty