=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033692926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENN A FELTZ, PSY.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2018
-----------------------------------------------------
Last Update Date | 09/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6792 QUARTERHORSE DR
-----------------------------------------------------
City | SPRINGBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45066-7780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-206-6502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11 6792 QUARTERHORSE DRIVE
-----------------------------------------------------
City | SPRINGBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-206-6502
-----------------------------------------------------
Fax | 937-550-4106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GLENN A FELTZ
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 937-206-6502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3924
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------