Healthcare Provider Details

I. General information

NPI: 1912281262
Provider Name (Legal Business Name): GLEN LAVARIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 DIPLOMACY DR SUITE 2300
ANCHORAGE AK
99508-5925
US

IV. Provider business mailing address

4320 DIPLOMACY DR SUITE 2300
ANCHORAGE AK
99508-5925
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-8825
  • Fax: 907-729-6154
Mailing address:
  • Phone: 907-729-8825
  • Fax: 907-729-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCP-5270-R
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401223735
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPCOP878
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: