Provider Demographics
NPI:1851863302
Name:FLEMING, GLEN VICTOR (BA SAC-IT)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:VICTOR
Last Name:FLEMING
Suffix:
Gender:M
Credentials:BA SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 NORTH 4TH STREET SUITE 210
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212
Mailing Address - Country:US
Mailing Address - Phone:414-263-6000
Mailing Address - Fax:414-263-2270
Practice Address - Street 1:2821 NORTH 4TH STREET SUITE 210
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-263-6000
Practice Address - Fax:414-263-2270
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18341-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)