Healthcare Provider Details

I. General information

NPI: 1033592894
Provider Name (Legal Business Name): GLU FACTORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N THORNTON ST SUITE F
CLOVIS NM
88101-5508
US

IV. Provider business mailing address

1200 N THORNTON ST SUITE F
CLOVIS NM
88101-5508
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-4458
  • Fax:
Mailing address:
  • Phone: 575-935-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: YVETTE PICKETT
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential: LMSW
Phone: 575-935-4458