MEDICARE: MS. MARY DELORES GLENN 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	101YP2500X	Professional Counselor	600085	TX

General Provider Information

NPI Number	:	1396994984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY DELORES GLENN LPC

Provider Business Mailing Address
First Line	:	2516 OAKLAND BLVD.
Second Line	:	SUITE 5
City	:	FORT WORTH
State	:	TX
Zip	:	76103
Country	:	US
Telephone Number	:	817-535-6300
Fax Number	:	817-535-4100

Provider Business Practice Location Address
First Line	:	2516 OAKLAND BLVD
Second Line	:	SUITE 5
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3201
Country	:	US
Telephone Number	:	817-535-6300
Fax Number	:	817-535-4100

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

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	09/18/2008

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