Healthcare Provider Details

I. General information

NPI: 1104630334
Provider Name (Legal Business Name): GLEN EGBERT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2025
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 W 15TH ST STE 500
FRONT ROYAL VA
22630-2847
US

IV. Provider business mailing address

1152 BOWLING GREEN RD
FRONT ROYAL VA
22630-7420
US

V. Phone/Fax

Practice location:
  • Phone: 540-635-2725
  • Fax: 540-635-3001
Mailing address:
  • Phone: 661-810-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPPS-0608920
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: