Provider Demographics
NPI:1598448235
Name:MOTOLA, GLENN CHARLES (PSYD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:CHARLES
Last Name:MOTOLA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 S RANCHO SANTA FE RD STE F50
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6334
Mailing Address - Country:US
Mailing Address - Phone:415-497-3369
Mailing Address - Fax:
Practice Address - Street 1:162 S RANCHO SANTA FE RD STE F50
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6334
Practice Address - Country:US
Practice Address - Phone:415-497-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34301103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty