Provider Demographics
NPI:1710011309
Name:BOATNER, GLENDA YVONNE (MSW, ACSW)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:YVONNE
Last Name:BOATNER
Suffix:
Gender:F
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4637
Mailing Address - Country:US
Mailing Address - Phone:909-629-2400
Mailing Address - Fax:
Practice Address - Street 1:2555 E COLORADO BLVD
Practice Address - Street 2:SUITE 100-101
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-6622
Practice Address - Country:US
Practice Address - Phone:626-577-2261
Practice Address - Fax:626-577-2543
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW12440101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN752OtherDMH STAFF CODE