Provider Demographics
NPI:1528517778
Name:HARRELL, GLENN JR
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:HARRELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 CAMBRIDGE ST APT 47
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2027
Mailing Address - Country:US
Mailing Address - Phone:225-394-5997
Mailing Address - Fax:
Practice Address - Street 1:10110 W SAM HOUSTON PKWY S STE 110
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-5153
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3884103K00000X
103K00000X
TX3484103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst