Provider Demographics
NPI:1629133004
Name:GLENNON, BERTIN R (PSYCHOLOGICAL EXAMIN)
Entity Type:Individual
Prefix:
First Name:BERTIN
Middle Name:R
Last Name:GLENNON
Suffix:
Gender:M
Credentials:PSYCHOLOGICAL EXAMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E 8TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-4062
Mailing Address - Country:US
Mailing Address - Phone:423-265-7935
Mailing Address - Fax:423-265-8204
Practice Address - Street 1:310 E 8TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-4062
Practice Address - Country:US
Practice Address - Phone:423-265-7935
Practice Address - Fax:423-265-8204
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000000289101Y00000X
TNPE0000011753103T00000X
TNLMT0000000027106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4024539OtherBLUECROSS