Provider Demographics
NPI:1336752476
Name:GLENN, KRYSTAL JANELLE (LCSW-A)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:JANELLE
Last Name:GLENN
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 BELLEAU WOODS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6290
Mailing Address - Country:US
Mailing Address - Phone:919-889-2663
Mailing Address - Fax:919-882-1277
Practice Address - Street 1:309 W MILLBROOK RD STE 161
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4261
Practice Address - Country:US
Practice Address - Phone:919-889-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27550101YA0400X
NCP0150071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)