Healthcare Provider Details

I. General information

NPI: 1437333937
Provider Name (Legal Business Name): CA TRICE B. GLENN LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 AUTRY ST
NORCROSS GA
30071-1919
US

IV. Provider business mailing address

3000 OLD ALABAMA RD SUITE 119-109
JOHNS CREEK GA
30022-5860
US

V. Phone/Fax

Practice location:
  • Phone: 770-464-5123
  • Fax:
Mailing address:
  • Phone: 770-464-5123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC001682
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006136
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: