Provider Demographics
NPI:1396587911
Name:GLENN, KATELYN ASHLEY
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ASHLEY
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:GLENN
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1273 W 12600 S STE 403
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7111
Mailing Address - Country:US
Mailing Address - Phone:385-259-4005
Mailing Address - Fax:
Practice Address - Street 1:1273 W 12600 S STE 403
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7111
Practice Address - Country:US
Practice Address - Phone:385-259-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist