=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154468148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT T. GLENN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5444 PARK BLVD SUITE 201
-----------------------------------------------------
City | PINELLAS PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33781-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-698-7549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13740 OAK FOREST BLVD N
-----------------------------------------------------
City | SEMINOLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33776-3413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-392-7554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT 0168
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------