Provider Demographics
NPI:1891459962
Name:GLAZEK, COLLIN
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:GLAZEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 E 39TH ST APT 101
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1713
Mailing Address - Country:US
Mailing Address - Phone:156-394-0679
Mailing Address - Fax:
Practice Address - Street 1:3625 UTICA RIDGE RD STE E
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1653
Practice Address - Country:US
Practice Address - Phone:563-526-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-21-12984106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst