Provider Demographics
NPI:1174979892
Name:GLENTZER, LAURA GAYLE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GAYLE
Last Name:GLENTZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 CLAREMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PAWHUSKA
Mailing Address - State:OK
Mailing Address - Zip Code:74056-1742
Mailing Address - Country:US
Mailing Address - Phone:918-214-7610
Mailing Address - Fax:
Practice Address - Street 1:1611 CLAREMORE AVE
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-1742
Practice Address - Country:US
Practice Address - Phone:918-214-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker