Provider Demographics
NPI:1669632006
Name:TANITA, GLENN DAVID (DMH)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DAVID
Last Name:TANITA
Suffix:
Gender:M
Credentials:DMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-459-3110
Mailing Address - Fax:
Practice Address - Street 1:77 CALLE PORTAL STE C240
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2986
Practice Address - Country:US
Practice Address - Phone:520-459-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-001249103T00000X
AZ1249103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist