Provider Demographics
NPI:1841686730
Name:SMITH, GLENNA CROSWELL (MD)
Entity type:Individual
Prefix:
First Name:GLENNA
Middle Name:CROSWELL
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 BALBOA BLVD STE 199
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1515
Mailing Address - Country:US
Mailing Address - Phone:818-643-5082
Mailing Address - Fax:818-643-7098
Practice Address - Street 1:6345 BALBOA BLVD STE 199
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1515
Practice Address - Country:US
Practice Address - Phone:818-643-5082
Practice Address - Fax:818-643-7098
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1559322084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program