MEDICARE: GABRIELLE SHAWNTA' GLENN MSED, LPC, LCMHCHA

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	101YM0800X	Mental Health Counselor	A20519	NC

General Provider Information

NPI Number	:	1831774892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE SHAWNTA' GLENN MSED, LPC, LCMHCHA

Provider Business Mailing Address
First Line	:	5821 FAIRVIEW RD STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-5601
Country	:	US
Telephone Number	:	980-308-4500
Fax Number	:	980-458-6037

Provider Business Practice Location Address
First Line	:	10150 MALLARD CREEK RD STE 509
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-9708
Country	:	US
Telephone Number	:	980-308-4500
Fax Number	:

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

Provider Enumeration Date	:	03/11/2021
Last Update Date	:	07/17/2025

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