Provider Demographics
NPI:1902395171
Name:GARCIA, GLENN THOMAS (LCSW)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:THOMAS
Last Name:GARCIA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-4228
Mailing Address - Fax:
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY108OtherLICENSED CLINICAL SOCIAL WORKER