Provider Demographics
NPI:1669896056
Name:COGNAC, GLEN (LCSW)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:COGNAC
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 N CONGRESS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3284
Mailing Address - Country:US
Mailing Address - Phone:561-316-8495
Mailing Address - Fax:561-828-8531
Practice Address - Street 1:4700 N CONGRESS AVE STE 104
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3284
Practice Address - Country:US
Practice Address - Phone:561-316-8495
Practice Address - Fax:561-828-8531
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW198751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical