Provider Demographics
NPI:1639642382
Name:GLENN, SHAQUITA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:SHAQUITA
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6528 W CENTER ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1845 N FARWELL AVE STE 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1715
Practice Address - Country:US
Practice Address - Phone:414-223-3815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3434-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health