Provider Demographics
NPI:1659650638
Name:WHITELAW, GLENN DOUGLAS CAMPBELL (LMSW, LMFT, ACSW, NA)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:DOUGLAS CAMPBELL
Last Name:WHITELAW
Suffix:
Gender:M
Credentials:LMSW, LMFT, ACSW, NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 E WEST MAPLE RD
Mailing Address - Street 2:SUITE D-407
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3801
Mailing Address - Country:US
Mailing Address - Phone:248-624-3811
Mailing Address - Fax:248-624-0368
Practice Address - Street 1:114 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2244
Practice Address - Country:US
Practice Address - Phone:248-858-7766
Practice Address - Fax:248-858-7201
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010171031041C0700X
MI4101005142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid
MI1883825Medicaid