Provider Demographics
NPI:1356544647
Name:GLENN, CHRISTINE GENEVIEVE (PHD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GENEVIEVE
Last Name:GLENN
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 1:7106 SW 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1851
Mailing Address - Country:US
Mailing Address - Phone:503-452-8087
Mailing Address - Fax:
Practice Address - Street 1:1815 NW FLANDERS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2060
Practice Address - Country:US
Practice Address - Phone:503-243-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR504103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical