Provider Demographics
NPI:1669565248
Name:GOOD, GLENN E (PHD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:E
Last Name:GOOD
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 1:1612 JESSE LANE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4721
Mailing Address - Country:US
Mailing Address - Phone:573-446-4929
Mailing Address - Fax:573-882-3084
Practice Address - Street 1:601 W. NIFONG BLVD.
Practice Address - Street 2:SUITE 2B
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6804
Practice Address - Country:US
Practice Address - Phone:573-446-4929
Practice Address - Fax:573-882-3084
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0271103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist