Provider Demographics
NPI:1205510575
Name:GLENN, ALICIA LAYNE (LMFT)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:LAYNE
Last Name:GLENN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:LAYNE
Other - Last Name:BRASGALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30724 BENTON RD STE C302
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8470
Mailing Address - Country:US
Mailing Address - Phone:951-551-1488
Mailing Address - Fax:
Practice Address - Street 1:28078 BAXTER RD STE 242
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1403
Practice Address - Country:US
Practice Address - Phone:951-290-6540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136246106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist