Provider Demographics
NPI:1710391719
Name:JOHNSON, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MAUPIN CIR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3781
Mailing Address - Country:US
Mailing Address - Phone:931-680-7576
Mailing Address - Fax:931-536-4346
Practice Address - Street 1:118 MAUPIN CIR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3781
Practice Address - Country:US
Practice Address - Phone:931-680-7576
Practice Address - Fax:931-536-4346
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE0000001718103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling