Provider Demographics
NPI:1720646094
Name:SCANES, GLENN WILBUR JR
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:WILBUR
Last Name:SCANES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BENT TREE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1195
Mailing Address - Country:US
Mailing Address - Phone:321-213-8065
Mailing Address - Fax:
Practice Address - Street 1:1823 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1230
Practice Address - Country:US
Practice Address - Phone:386-255-5818
Practice Address - Fax:386-255-5818
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSOJXQXJM6Medicaid