Provider Demographics
NPI:1023138252
Name:MURRY, GLENN (PSYCH TECH)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:MURRY
Suffix:
Gender:M
Credentials:PSYCH TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28505 HIGHWAY 190
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-9616
Mailing Address - Country:US
Mailing Address - Phone:559-791-9298
Mailing Address - Fax:
Practice Address - Street 1:1701 W KANAI AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1873
Practice Address - Country:US
Practice Address - Phone:559-782-8136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30578167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician