Provider Demographics
NPI:1912281262
Name:LAVARIAS, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:LAVARIAS
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 1:4320 DIPLOMACY DR
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5925
Mailing Address - Country:US
Mailing Address - Phone:907-729-8825
Mailing Address - Fax:907-729-6154
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:SUITE 2300
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-8825
Practice Address - Fax:907-729-6154
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist