Healthcare Provider Details

I. General information

NPI: 1275445009
Provider Name (Legal Business Name): GLENN OTIS WEST JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 E THOUSAND OAKS BLVD
THOUSAND OAKS CA
91362-2806
US

IV. Provider business mailing address

772 E THOUSAND OAKS BLVD
THOUSAND OAKS CA
91360-6055
US

V. Phone/Fax

Practice location:
  • Phone: 805-341-8875
  • Fax:
Mailing address:
  • Phone: 805-794-8451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1600990225
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: