Provider Demographics
NPI:1295734929
Name:MEARS, GLEN ALLEN (LCSW)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ALLEN
Last Name:MEARS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 117
Mailing Address - Street 2:
Mailing Address - City:HOEHNE
Mailing Address - State:CO
Mailing Address - Zip Code:81046-0117
Mailing Address - Country:US
Mailing Address - Phone:719-845-7956
Mailing Address - Fax:
Practice Address - Street 1:412 BENEDICTA AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2005
Practice Address - Country:US
Practice Address - Phone:719-846-2213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX534001041C0700X, 1041C0700X
COCSW.099244471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical