Provider Demographics
NPI:1356540678
Name:BOAK GLAHN, VIRGINIA L (LMHC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:L
Last Name:BOAK GLAHN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:LYNN
Other - Last Name:GLAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-0853
Mailing Address - Country:US
Mailing Address - Phone:315-935-5358
Mailing Address - Fax:
Practice Address - Street 1:661 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-9111
Practice Address - Country:US
Practice Address - Phone:315-935-5358
Practice Address - Fax:315-668-1073
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP58666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health