Provider Demographics
NPI:1396279220
Name:STAMPS, GLEN MATTHEW JR (LPC-MHSP)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:MATTHEW
Last Name:STAMPS
Suffix:JR
Gender:M
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5583 MURRAY AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0807
Mailing Address - Country:US
Mailing Address - Phone:901-590-2193
Mailing Address - Fax:
Practice Address - Street 1:5583 MURRAY AVE STE 207
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-590-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3869101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor