Provider Demographics
NPI:1689618514
Name:STOVALL, GLEN EUGENE (MSW)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:EUGENE
Last Name:STOVALL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E IRON AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-2697
Mailing Address - Country:US
Mailing Address - Phone:785-827-2700
Mailing Address - Fax:785-309-0184
Practice Address - Street 1:645 E IRON AVE
Practice Address - Street 2:SUITE D
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2697
Practice Address - Country:US
Practice Address - Phone:785-827-2700
Practice Address - Fax:785-309-0184
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 10781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS91946OtherMANAGED HEALTH NETWORK
KS32748OtherCIGNA
KS100097970AMedicaid
KS011556OtherBLUE CROSS BLUE SHIELD
KS011556Medicare PIN