MEDICARE: MS. TAMALA DE JEANE GLENN LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	63006	TX

General Provider Information

NPI Number	:	1942439534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TAMALA DE JEANE GLENN LPC

Provider Business Mailing Address
First Line	:	2750 HOLLY HALL STREET
Second Line	:	#1204
City	:	HOUSTON
State	:	TX
Zip	:	77054-4109
Country	:	US
Telephone Number	:	832-277-8960
Fax Number	:

Provider Business Practice Location Address
First Line	:	2750 HOLLY HALL ST
Second Line	:	#1204
City	:	HOUSTON
State	:	TX
Zip	:	77054-4109
Country	:	US
Telephone Number	:	832-277-8960
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2009
Last Update Date	:	07/06/2009

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