Provider Demographics
NPI:1255903845
Name:CANTER, GLEN ANDREW JR (LPT)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ANDREW
Last Name:CANTER
Suffix:JR
Gender:M
Credentials:LPT
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Mailing Address - Street 1:4332 TRANQUILLA AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2867
Mailing Address - Country:US
Mailing Address - Phone:805-234-4713
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA32987167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician