Provider Demographics
NPI:1881132744
Name:GLINKA, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:GLINKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 BUTTERWORTH ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-6164
Mailing Address - Country:US
Mailing Address - Phone:810-922-2610
Mailing Address - Fax:
Practice Address - Street 1:1149 BUTTERWORTH ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504
Practice Address - Country:US
Practice Address - Phone:810-922-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIG 452 122 564 507106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
730763OtherUNITED HEALTHCARE