Provider Demographics
NPI:1548323850
Name:GLYNN, SHIRLEY M (PHD)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:M
Last Name:GLYNN
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 1:100 E THOUSAND OAKS BLVD
Mailing Address - Street 2:SUITE 236
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5713
Mailing Address - Country:US
Mailing Address - Phone:805-495-8984
Mailing Address - Fax:805-495-3439
Practice Address - Street 1:100 E THOUSAND OAKS BLVD
Practice Address - Street 2:SUITE 236
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5713
Practice Address - Country:US
Practice Address - Phone:805-495-8984
Practice Address - Fax:805-495-3439
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 10282103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10282Medicare ID - Type Unspecified