Provider Demographics
NPI:1801801477
Name:ASHKANAZI, GLENN STEVEN (PHD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:STEVEN
Last Name:ASHKANAZI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:STEVEN
Other - Last Name:ASHKANAZI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-0294
Mailing Address - Fax:352-265-0096
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0294
Practice Address - Fax:352-265-0096
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5365103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL211997800Medicaid
FL211997800Medicaid
FLE3117Medicare ID - Type Unspecified