Healthcare Provider Details

I. General information

NPI: 1932144615
Provider Name (Legal Business Name): GLEN M WURGLITZ PYSD, HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14780 W MOUNTAIN VIEW BLVD STE 210
SURPRISE AZ
85374-7281
US

IV. Provider business mailing address

14667 W COLUMBINE DR
SURPRISE AZ
85379-5698
US

V. Phone/Fax

Practice location:
  • Phone: 630-360-7309
  • Fax:
Mailing address:
  • Phone: 630-390-8436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041231A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005590
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015915
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY005163
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: