Provider Demographics
NPI:1922517838
Name:MERRIEWETHER, GLYNN
Entity Type:Individual
Prefix:
First Name:GLYNN
Middle Name:
Last Name:MERRIEWETHER
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 1:24791 PARKSIDE ST APT 206
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-3614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19321 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1739
Practice Address - Country:US
Practice Address - Phone:586-846-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336674415Medicaid