Provider Demographics
NPI:1881792059
Name:VOLLENWEIDER, GLEN P (PHD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:P
Last Name:VOLLENWEIDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 N DEAN RD STE D
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-9421
Mailing Address - Country:US
Mailing Address - Phone:334-887-4343
Mailing Address - Fax:334-887-5656
Practice Address - Street 1:861 N DEAN RD STE D
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-9421
Practice Address - Country:US
Practice Address - Phone:334-887-4343
Practice Address - Fax:334-887-5656
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1167103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL890012250Medicaid
530 742000OtherMAGELLAN
AL515-19144OtherBCBS OF ALABAMA
AL529909220Medicaid