Healthcare Provider Details

I. General information

NPI: 1093421414
Provider Name (Legal Business Name): KASSONDRA GLENN LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 PARK AVE SW
ALBUQUERQUE NM
87102-4565
US

IV. Provider business mailing address

PO BOX 11
ALBUQUERQUE NM
87103-0011
US

V. Phone/Fax

Practice location:
  • Phone: 917-819-2883
  • Fax:
Mailing address:
  • Phone:
  • 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: KASSONDRA GLENN
Title or Position: OWNER
Credential: LCSW
Phone: 917-819-2883