Healthcare Provider Details

I. General information

NPI: 1750016010
Provider Name (Legal Business Name): DIANE CAROL GLENN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9415 E HARRY ST
WICHITA KS
67207-5089
US

IV. Provider business mailing address

1729 S SAINT CLAIR AVE
WICHITA KS
67213-2916
US

V. Phone/Fax

Practice location:
  • Phone: 316-652-2590
  • Fax:
Mailing address:
  • Phone: 620-408-6078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: