Provider Demographics
NPI:1902968795
Name:KING, GLEN D (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:D
Last Name:KING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1520
Mailing Address - Country:US
Mailing Address - Phone:334-269-1106
Mailing Address - Fax:334-832-9557
Practice Address - Street 1:1520 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1520
Practice Address - Country:US
Practice Address - Phone:334-269-1106
Practice Address - Fax:334-832-9557
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL137103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL70974KINOther70974KIN
AL70974KINOther70974KIN