Provider Demographics
NPI:1760697908
Name:CLOUSE, GLENN CHARLES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:CHARLES
Last Name:CLOUSE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4554 E INVERNESS AVE
Mailing Address - Street 2:SUITE C-11
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4554 E INVERNESS AVE
Practice Address - Street 2:SUITE C-11
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4639
Practice Address - Country:US
Practice Address - Phone:480-226-0917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical