Provider Demographics
NPI:1003663881
Name:HOLM, GLENNA MARIE
Entity type:Individual
Prefix:
First Name:GLENNA
Middle Name:MARIE
Last Name:HOLM
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 1:10912 75TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8405
Mailing Address - Country:US
Mailing Address - Phone:262-960-3983
Mailing Address - Fax:
Practice Address - Street 1:1530 S SHIELDS DR
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-8307
Practice Address - Country:US
Practice Address - Phone:877-270-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst