Provider Demographics
NPI:1831177716
Name:SMITH, GLENN E (PHD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:#100165
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0165
Mailing Address - Country:US
Mailing Address - Phone:352-273-6556
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:#100165
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0165
Practice Address - Country:US
Practice Address - Phone:352-273-6556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9386103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R64298Medicare UPIN
FLII091ZMedicare PIN