Provider Demographics
NPI:1831243054
Name:GLENN, LEROY WILSON JR (LCAS)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:WILSON
Last Name:GLENN
Suffix:JR
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 SANTOLINA LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-8622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 EAST FIRST AVENUE EXTENSION
Practice Address - Street 2:SUITE 10
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-3355
Practice Address - Country:US
Practice Address - Phone:336-242-2450
Practice Address - Fax:336-249-9920
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC688101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC688OtherLCAS