Provider Demographics
NPI:1477065720
Name:NILES, GLENN A (LPC)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:NILES
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4039 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-3389
Mailing Address - Country:US
Mailing Address - Phone:706-498-9570
Mailing Address - Fax:
Practice Address - Street 1:4039 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-3389
Practice Address - Country:US
Practice Address - Phone:706-498-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009918101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid