Healthcare Provider Details

I. General information

NPI: 1144774639
Provider Name (Legal Business Name): GLENN D WILLIAMS D.MIN, P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UPS DR SUITE 107
LOUISVILLE KY
40223-4046
US

IV. Provider business mailing address

1700 UPS DR SUITE 107
LOUISVILLE KY
40223-4046
US

V. Phone/Fax

Practice location:
  • Phone: 502-339-4511
  • Fax: 502-339-4513
Mailing address:
  • Phone: 502-339-4511
  • Fax: 502-339-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number127375
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: