Provider Demographics
NPI:1689897860
Name:GLENN, MARY K (SAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:GLENN
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3279 PINGREE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2103
Mailing Address - Country:US
Mailing Address - Phone:313-895-1836
Mailing Address - Fax:
Practice Address - Street 1:8809 JOHN C. LODGE SERVICE DRIVE
Practice Address - Street 2:BUILDING #5
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-887-6721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)