Provider Demographics
NPI:1730854993
Name:ANDERSON, GLENN J
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:J
Last Name:ANDERSON
Suffix:
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 1:764 S PALOMAR PL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-2666
Mailing Address - Country:US
Mailing Address - Phone:719-299-6777
Mailing Address - Fax:
Practice Address - Street 1:19 E ABARR DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5436
Practice Address - Country:US
Practice Address - Phone:719-404-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist