Provider Demographics
NPI:1780622860
Name:CROSS, GLEN WILLIAM (LMHC)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:WILLIAM
Last Name:CROSS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7690 CASTLEBERRY TER
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-7882
Mailing Address - Country:US
Mailing Address - Phone:401-450-6494
Mailing Address - Fax:
Practice Address - Street 1:7690 CASTLEBERRY TER
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-7882
Practice Address - Country:US
Practice Address - Phone:401-450-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1104847946OtherTHE PROVIDENCE CENTER NPI
RI407903OtherBLUE CHIP
RI62-40330OtherUNITED BEHAVIORAL HEALTH
RI30009-0OtherBLUE CROSS
RIGC27077Medicaid