Provider Demographics
NPI:1619194750
Name:COTTAM, GLENDA LUCILLE (PHD JD)
Entity Type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:LUCILLE
Last Name:COTTAM
Suffix:
Gender:F
Credentials:PHD JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 S 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3045
Mailing Address - Country:US
Mailing Address - Phone:402-331-8085
Mailing Address - Fax:402-331-8265
Practice Address - Street 1:2730 S 87TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3045
Practice Address - Country:US
Practice Address - Phone:402-331-8085
Practice Address - Fax:402-331-8265
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE230103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical