Healthcare Provider Details

I. General information

NPI: 1043991771
Provider Name (Legal Business Name): ALITHA V GLENN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MICHIGAN 19259 LINVILLE ST
GROSSE POINTE WOODS MI
48236
US

IV. Provider business mailing address

MICHIGAN 19259 LINVILLE ST
GROSSE POINTE WOODS MI
48236
US

V. Phone/Fax

Practice location:
  • Phone: 248-346-6959
  • Fax:
Mailing address:
  • Phone: 248-346-6959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704281299
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704281299
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: