Healthcare Provider Details

I. General information

NPI: 1568549251
Provider Name (Legal Business Name): GLENN FLEISCH PH.D., MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 TENNESSEE ST
VALLEJO CA
94590-4431
US

IV. Provider business mailing address

526 TENNESSEE ST
VALLEJO CA
94590-4431
US

V. Phone/Fax

Practice location:
  • Phone: 707-644-5421
  • Fax: 530-622-2793
Mailing address:
  • Phone: 707-644-5421
  • Fax: 530-622-2793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC12608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: