MEDICARE: MR. GLENN HOWARD MAYES LCSW

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	1041C0700X	Clinical Social Worker	1197	OK

General Provider Information

NPI Number	:	1508876749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLENN HOWARD MAYES LCSW

Provider Business Mailing Address
First Line	:	1801 SW 68TH ST
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73505-9030
Country	:	US
Telephone Number	:	580-536-7354
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG. 4303 PITMAN AND THOMAS
Second Line	:
City	:	FT. SILL
State	:	OK
Zip	:	73503
Country	:	US
Telephone Number	:	580-353-1131
Fax Number	:	580-353-0340

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2007

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