Provider Demographics
NPI:1174696413
Name:GLENN WIXSON, JOEL NATHAN (PSYD CAS)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:NATHAN
Last Name:GLENN WIXSON
Suffix:
Gender:M
Credentials:PSYD CAS
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Mailing Address - Street 1:539 ISLINGTON ST
Mailing Address - Street 2:5
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801
Mailing Address - Country:US
Mailing Address - Phone:603-427-6858
Mailing Address - Fax:603-427-6555
Practice Address - Street 1:539 ISLINGTON ST
Practice Address - Street 2:5
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-427-6858
Practice Address - Fax:603-427-6555
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH1056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH06Y00744INH01OtherANTHEM BCBS
NH304ZO374Medicaid
NH304ZO374Medicaid