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General NPI Number Information
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NPI Number | 1154024834
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Entity Type | Individual
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Provider Name | GLENN WANDEN BROOKS JR.
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Gender | Male
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Dates
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Enumeration Date | 03/23/2023
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Last Update Date | 03/07/2024
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Provider Practice Location Address
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Address Line | 790 S STATE ST
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City | SAN JACINTO
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State | CA
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Zip | 92583-4926
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Country | US
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Telephone | 951-623-6728
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Fax |
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Provider Business Mailing Address
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Address Line | 377 RECOGNITION LN
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City | PERRIS
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State | CA
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Zip | 92571-2907
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Country | US
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Telephone | 951-623-6728
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 136527
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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