Provider Demographics
NPI:1508921917
Name:BAILEY, GLENN THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:THOMAS
Last Name:BAILEY
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 1:4000 STERRETTANIA RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4125
Mailing Address - Country:US
Mailing Address - Phone:814-454-4285
Mailing Address - Fax:814-520-8490
Practice Address - Street 1:4000 STERRETTANIA RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4125
Practice Address - Country:US
Practice Address - Phone:814-454-4285
Practice Address - Fax:814-520-8490
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005734L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
644836Medicare ID - Type Unspecified