Provider Demographics
NPI:1811907843
Name:BEGROW JR., GLEN PAUL (LCSW)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:PAUL
Last Name:BEGROW JR.
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:169 N 9TH AVE
Mailing Address - Street 2:UPPER
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1729
Mailing Address - Country:US
Mailing Address - Phone:920-746-2533
Mailing Address - Fax:920-746-2439
Practice Address - Street 1:421 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2249
Practice Address - Country:US
Practice Address - Phone:920-746-2533
Practice Address - Fax:920-746-2439
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7314-1231041C0700X, 101YP2500X, 106H00000X, 101YM0800X, 101Y00000X, 104100000X, 171M00000X
NY0716021041C0700X, 101YP2500X, 101YM0800X, 102L00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI001484416Medicare PIN