Provider Demographics
NPI:1487128567
Name:GLENN, CRYSTAL CIANNE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CIANNE
Last Name:GLENN
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 1:710 CHEROKEE DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-3323
Mailing Address - Country:US
Mailing Address - Phone:661-599-3112
Mailing Address - Fax:
Practice Address - Street 1:3105 WILSON RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93304-5319
Practice Address - Country:US
Practice Address - Phone:661-397-8775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist