Healthcare Provider Details

I. General information

NPI: 1841339751
Provider Name (Legal Business Name): GLENN NEWSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 W CONE BLVD STE 100
GREENSBORO NC
27408-4027
US

IV. Provider business mailing address

2307 W CONE BLVD STE 100
GREENSBORO NC
27408-4027
US

V. Phone/Fax

Practice location:
  • Phone: 336-662-8185
  • Fax: 336-665-6188
Mailing address:
  • Phone: 336-662-8185
  • Fax: 336-665-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4085
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: