MEDICARE: MR. DENNIS J GLANDON CSW LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	6801016082	MI
2	104100000X	Social Worker	6301002109	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041285	OTHER	MI	VALUE OPTOINS STATE OF MI
2	8008970870	OTHER	MI	TRADITIONAL BLUE CROSS B

General Provider Information

NPI Number	:	1366496051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS J GLANDON CSW LPC

Provider Business Mailing Address
First Line	:	1200 N WEST AVE
Second Line	:	SUITE 400
City	:	JACKSON
State	:	MI
Zip	:	49202-2179
Country	:	US
Telephone Number	:	517-780-3336
Fax Number	:	517-796-4561

Provider Business Practice Location Address
First Line	:	1200 N WEST AVE
Second Line	:	SUITE 400
City	:	JACKSON
State	:	MI
Zip	:	49202-2179
Country	:	US
Telephone Number	:	517-780-3336
Fax Number	:	517-796-4561

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	03/28/2008

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