Provider Demographics
NPI:1912498890
Name:GLENN, VIKEASHA
Entity Type:Individual
Prefix:MRS
First Name:VIKEASHA
Middle Name:
Last Name:GLENN
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 1:2101 CRAWFORD ST STE 208
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-8941
Mailing Address - Country:US
Mailing Address - Phone:713-739-9725
Mailing Address - Fax:866-242-3803
Practice Address - Street 1:2101 CRAWFORD ST STE 208
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8941
Practice Address - Country:US
Practice Address - Phone:713-739-9725
Practice Address - Fax:866-242-3803
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3612756Medicaid