MEDICARE: GLENN J ANDERSON

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1730854993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN J ANDERSON

Provider Business Mailing Address
First Line	:	764 S PALOMAR PL
Second Line	:
City	:	PUEBLO WEST
State	:	CO
Zip	:	81007-2666
Country	:	US
Telephone Number	:	719-299-6777
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 E ABARR DR
Second Line	:
City	:	PUEBLO WEST
State	:	CO
Zip	:	81007-5436
Country	:	US
Telephone Number	:	719-404-6618
Fax Number	:

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

Provider Enumeration Date	:	08/10/2021
Last Update Date	:	03/09/2023

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Directions to “ GLENN J ANDERSON ” Practice Location

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