Provider Demographics
NPI:1942240742
Name:HARSCH, GLENN DALE
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:DALE
Last Name:HARSCH
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 1:8424 PORTMARNOCK CT
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9419
Mailing Address - Country:US
Mailing Address - Phone:919-761-9597
Mailing Address - Fax:919-212-8644
Practice Address - Street 1:8424 PORTMARNOCK CT
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-9419
Practice Address - Country:US
Practice Address - Phone:919-761-9597
Practice Address - Fax:919-212-8640
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2042101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2342249OtherGROUP MEDICARE