Healthcare Provider Details

I. General information

NPI: 1053727826
Provider Name (Legal Business Name): MARGARET ROSE GLENN LCSW,ACHP-SW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 US HIGHWAY 17 SUITE 103
FLEMING ISLAND FL
32003-4832
US

IV. Provider business mailing address

4375 US HIGHWAY 17 SUITE 103
FLEMING ISLAND FL
32003-4832
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-0886
  • Fax: 904-269-0499
Mailing address:
  • Phone: 904-236-0507
  • Fax: 904-269-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW3666
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: