Provider Demographics
NPI:1730539024
Name:GLENN, KEVIN LLOYD (LAC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LLOYD
Last Name:GLENN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 S STAPLEY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5877
Mailing Address - Country:US
Mailing Address - Phone:480-892-7403
Mailing Address - Fax:480-892-6701
Practice Address - Street 1:1424 S STAPLEY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5877
Practice Address - Country:US
Practice Address - Phone:480-892-7403
Practice Address - Fax:480-892-6701
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-15190101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health