Provider Demographics
NPI:1336347244
Name:GLEN, BRUCE LEON (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEON
Last Name:GLEN
Suffix:
Gender:M
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:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1269
Mailing Address - Country:US
Mailing Address - Phone:808-572-6556
Mailing Address - Fax:808-573-1189
Practice Address - Street 1:1940 OLINDA RD
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-7101
Practice Address - Country:US
Practice Address - Phone:808-572-6556
Practice Address - Fax:808-573-1189
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI396103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist