Provider Demographics
NPI:1770672362
Name:ANDERSON, GLENN R (MFTI)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 LONETREE BLVD STE 208C
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3794
Mailing Address - Country:US
Mailing Address - Phone:916-477-0528
Mailing Address - Fax:
Practice Address - Street 1:614 LORETTO DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-722-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 49658106H00000X
CA84277106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA84277OtherLICENSED MFT
CAIMF 49658OtherMFTI