Provider Demographics
NPI:1629411467
Name:HOUSE, GLENN C (LLPC/LLMFT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:C
Last Name:HOUSE
Suffix:
Gender:M
Credentials:LLPC/LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4886 SCARBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9012
Mailing Address - Country:US
Mailing Address - Phone:517-392-0366
Mailing Address - Fax:
Practice Address - Street 1:4886 SCARBOROUGH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9012
Practice Address - Country:US
Practice Address - Phone:517-392-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI601013113101YP2500X
MI4101006535106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist