Healthcare Provider Details

I. General information

NPI: 1548749898
Provider Name (Legal Business Name): CAITLIN GLENN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 E COAST HWY STE 209
CORONA DEL MAR CA
92625-2131
US

IV. Provider business mailing address

213 AVENIDA DE LA GRULLA
SAN CLEMENTE CA
92672-5021
US

V. Phone/Fax

Practice location:
  • Phone: 949-702-9453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number79953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: