Provider Demographics
NPI:1831909555
Name:GLENN, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GLENN
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 1:20 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-2531
Mailing Address - Country:US
Mailing Address - Phone:330-719-5829
Mailing Address - Fax:
Practice Address - Street 1:20 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2531
Practice Address - Country:US
Practice Address - Phone:330-719-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLSP.02439103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool