Provider Demographics
NPI:1972570257
Name:FRESE, GLEN A (PSYD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:FRESE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 N MILLER ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2044
Mailing Address - Country:US
Mailing Address - Phone:509-663-3977
Mailing Address - Fax:509-663-3109
Practice Address - Street 1:656 N MILLER ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2044
Practice Address - Country:US
Practice Address - Phone:509-663-3977
Practice Address - Fax:509-663-3109
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-04
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA990103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0024078OtherLABOR AND INDUSTRIES
WA000315457Medicare UPIN