Provider Demographics
NPI:1588859482
Name:THOMAS, GLENN (CLINICAL SOCIAL WORK)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 S BASCOM AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2652
Mailing Address - Country:US
Mailing Address - Phone:408-793-4241
Mailing Address - Fax:408-793-5955
Practice Address - Street 1:828 S BASCOM AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2652
Practice Address - Country:US
Practice Address - Phone:408-793-4241
Practice Address - Fax:408-793-5955
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical