Provider Demographics
NPI:1790266807
Name:GLENN, KEVIN MICHAEL (ASSOCIATE COUNSELOR)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:GLENN
Suffix:
Gender:M
Credentials:ASSOCIATE COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 WATSON ST APT B
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7903
Mailing Address - Country:US
Mailing Address - Phone:484-431-1186
Mailing Address - Fax:
Practice Address - Street 1:659 ABREGO ST STE 3
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-3238
Practice Address - Country:US
Practice Address - Phone:484-431-1186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional