Provider Demographics
NPI:1184610735
Name:GLENN, AUDREY A (PHD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:A
Last Name:GLENN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 RUSTON WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5378
Mailing Address - Country:US
Mailing Address - Phone:253-566-2850
Mailing Address - Fax:253-761-3288
Practice Address - Street 1:4041 RUSTON WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5378
Practice Address - Country:US
Practice Address - Phone:253-566-2850
Practice Address - Fax:253-761-3288
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY1225103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGL0001OtherREGENCE BLUE SHIELD ID