Provider Demographics
NPI:1255794137
Name:BRANTLEY, GLENN
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 SEAVIEW AVE.
Mailing Address - Street 2:SOUTH BEACH PSYCHIATRIC CENTER
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:718-668-8061
Mailing Address - Fax:718-668-8070
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:SBPC:HEALTH HOME PROGRAM
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305
Practice Address - Country:US
Practice Address - Phone:718-668-8061
Practice Address - Fax:718-668-8070
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00769306Medicaid