Provider Demographics
NPI:1811014012
Name:TRUEBLOOD, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:TRUEBLOOD
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 1:965 SW EMKAY DR
Mailing Address - Street 2:STE 200
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3598
Mailing Address - Country:US
Mailing Address - Phone:541-385-5203
Mailing Address - Fax:541-385-4724
Practice Address - Street 1:26 NW IRVING
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-385-5203
Practice Address - Fax:541-385-4724
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1200103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR084157Medicaid
ORR81901Medicare UPIN