Healthcare Provider Details

I. General information

NPI: 1477065720
Provider Name (Legal Business Name): GLENN A NILES LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4039 GATEWAY BLVD
GROVETOWN GA
30813-3389
US

IV. Provider business mailing address

4039 GATEWAY BLVD
GROVETOWN GA
30813-3389
US

V. Phone/Fax

Practice location:
  • Phone: 706-498-9570
  • Fax:
Mailing address:
  • Phone: 706-498-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009918
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: