Provider Demographics
NPI:1508172859
Name:AHAVA, GLENN W (PHD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:W
Last Name:AHAVA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FLUME RUN APT 102
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-8900
Mailing Address - Country:US
Mailing Address - Phone:478-595-3400
Mailing Address - Fax:
Practice Address - Street 1:700 FLUME RUN APT 102
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-8900
Practice Address - Country:US
Practice Address - Phone:478-595-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810-002514103TC0700X
LA1070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty