Provider Demographics
NPI:1649311481
Name:MCGOWAN, GLENN RICHARD (MA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:RICHARD
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 UNION RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6720
Mailing Address - Country:US
Mailing Address - Phone:314-638-9011
Mailing Address - Fax:
Practice Address - Street 1:717 UNION RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6720
Practice Address - Country:US
Practice Address - Phone:314-638-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL10284101YA0400X
MONCGC371-19101YM0800X
MOSW0026141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical