Provider Demographics
NPI:1932144615
Name:WURGLITZ, GLEN M (PYSD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:M
Last Name:WURGLITZ
Suffix:
Gender:M
Credentials:PYSD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14667 W COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5698
Mailing Address - Country:US
Mailing Address - Phone:630-390-8436
Mailing Address - Fax:
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7281
Practice Address - Country:US
Practice Address - Phone:630-360-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
IN20041231A103TC0700X
IL071005590103TC0700X
MI6301015915103TC0700X
AZPSY005163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200918700Medicaid