Provider Demographics
NPI:1700926664
Name:GLENN, DORETHA D (SLP,MSP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:DORETHA
Middle Name:D
Last Name:GLENN
Suffix:
Gender:F
Credentials:SLP,MSP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SAINT GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6973
Mailing Address - Country:US
Mailing Address - Phone:803-517-1382
Mailing Address - Fax:
Practice Address - Street 1:501 SAINT GEORGE RD
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6973
Practice Address - Country:US
Practice Address - Phone:803-517-1382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6329235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412292Medicaid