Healthcare Provider Details

I. General information

NPI: 1891851051
Provider Name (Legal Business Name): DENISE GLANVILLE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W PONCE DE LEON AVE SUITE 1051
DECATUR GA
30030-2400
US

IV. Provider business mailing address

3316 S COBB DR SE STE A SUITE 324
SMYRNA GA
30080-4107
US

V. Phone/Fax

Practice location:
  • Phone: 404-378-0441
  • Fax:
Mailing address:
  • Phone: 404-966-7505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003074
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY003074
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY003074
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04127
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: