Provider Demographics
NPI:1548604531
Name:SMITH, GLENDA WILSON (MA EDS)
Entity type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:WILSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HYLE AVE
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-8535
Mailing Address - Country:US
Mailing Address - Phone:615-410-6311
Mailing Address - Fax:
Practice Address - Street 1:250 HYLE AVE
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-8535
Practice Address - Country:US
Practice Address - Phone:615-410-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE0000011477103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist