Provider Demographics
NPI:1720868557
Name:GLENN, BRAYDEN MICHAEL
Entity Type:Individual
Prefix:
First Name:BRAYDEN
Middle Name:MICHAEL
Last Name:GLENN
Suffix:
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 1:58 LENDER ST
Mailing Address - Street 2:
Mailing Address - City:FLOMATON
Mailing Address - State:AL
Mailing Address - Zip Code:36441-5700
Mailing Address - Country:US
Mailing Address - Phone:251-359-0742
Mailing Address - Fax:
Practice Address - Street 1:6479 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4502
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician