Provider Demographics
NPI:1669488235
Name:MCGLENN, ROBERT LAWRENCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:MCGLENN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 CHILDRENS WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4232
Mailing Address - Country:US
Mailing Address - Phone:858-966-6751
Mailing Address - Fax:858-966-6753
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-966-6751
Practice Address - Fax:858-966-6753
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPL5209Medicaid
CAPL5209Medicaid