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General NPI Number Information
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NPI Number | 1104308683
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Entity Type | Individual
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Provider Name | DAVID GLEGHORN
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Gender | Male
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Dates
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Enumeration Date | 08/31/2018
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Last Update Date | 08/31/2018
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Provider Practice Location Address
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Address Line | 6610 N 47TH AVE STE 678
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City | GLENDALE
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State | AZ
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Zip | 85301-4163
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Country | US
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Telephone | 480-826-5686
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Fax |
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Provider Business Mailing Address
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Address Line | 1830 S ALMA SCHOOL RD STE 101
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City | MESA
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State | AZ
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Zip | 85210-3086
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LISAC-1043
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License Number State | AZ
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