=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023609831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDA GLENNY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2021
-----------------------------------------------------
Last Update Date | 03/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4025 HIGHWAY 178
-----------------------------------------------------
City | JAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32565-7306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-246-0567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1734 COBB RD
-----------------------------------------------------
City | BAKER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32531-8136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-246-0567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | LINDA GLENNY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-246-0567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------