Provider Demographics
NPI:1912012170
Name:GLENN, TANIA (PSYD, LCSW)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 CLAYTON LN STE 445E
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-2414
Mailing Address - Country:US
Mailing Address - Phone:512-323-6994
Mailing Address - Fax:512-323-9490
Practice Address - Street 1:1106 CLAYTON LN STE 445E
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2414
Practice Address - Country:US
Practice Address - Phone:512-323-6994
Practice Address - Fax:512-323-9490
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00063PMedicare ID - Type Unspecified
TXP18574Medicare UPIN