Provider Demographics
NPI:1952369613
Name:STOCKWELL, GLENDA F (PHD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:F
Last Name:STOCKWELL
Suffix:
Gender:F
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-245-9600
Mailing Address - Fax:423-245-9634
Practice Address - Street 1:102 E RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3814
Practice Address - Country:US
Practice Address - Phone:423-245-9600
Practice Address - Fax:423-245-9634
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPO2636103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3983274Medicaid