Provider Demographics
NPI:1619995669
Name:MCCLAUGHERTY, GLENN KELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:KELLIS
Last Name:MCCLAUGHERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W CRISER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-2360
Mailing Address - Country:US
Mailing Address - Phone:540-636-4250
Mailing Address - Fax:540-636-7171
Practice Address - Street 1:209 W CRISER RD
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-2360
Practice Address - Country:US
Practice Address - Phone:540-636-2931
Practice Address - Fax:540-636-2933
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010494252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA088195OtherSENTARA
VA1619995669Medicaid
VA7172699Medicaid