Provider Demographics
NPI:1457796369
Name:GLENN, EVERETT TETUSHI (ASW)
Entity Type:Individual
Prefix:
First Name:EVERETT
Middle Name:TETUSHI
Last Name:GLENN
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39500 STEVENSON PL STE 203
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-3103
Mailing Address - Country:US
Mailing Address - Phone:510-984-1654
Mailing Address - Fax:
Practice Address - Street 1:39500 STEVENSON PL STE 203
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-3103
Practice Address - Country:US
Practice Address - Phone:510-984-1654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70294101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor