Healthcare Provider Details

I. General information

NPI: 1588916738
Provider Name (Legal Business Name): GLENN GRIFFIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CAMPUS RD
LOS ANGELES CA
90041-3314
US

IV. Provider business mailing address

1600 CAMPUS RD
LOS ANGELES CA
90041-3314
US

V. Phone/Fax

Practice location:
  • Phone: 323-259-2799
  • Fax:
Mailing address:
  • Phone: 626-497-4134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12813
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY12813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: