Healthcare Provider Details

I. General information

NPI: 1841910114
Provider Name (Legal Business Name): GLEN COURTNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E 45TH ST
SHAWNEE OK
74804-2202
US

IV. Provider business mailing address

36609 45TH ST
SHAWNEE OK
74804-8882
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-1170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number12263
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: