Provider Demographics
NPI:1558870725
Name:GLENN, TELESIA
Entity Type:Individual
Prefix:
First Name:TELESIA
Middle Name:
Last Name:GLENN
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 1:5600 RICKENBACKER RD BLDG 2AB
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-6694
Mailing Address - Country:US
Mailing Address - Phone:3233-263-1206
Mailing Address - Fax:323-236-8543
Practice Address - Street 1:5600 RICKENBACKER RD BLDG 2AB
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-6694
Practice Address - Country:US
Practice Address - Phone:3233-263-1206
Practice Address - Fax:323-236-8543
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC23881214171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator