Provider Demographics
NPI:1447247960
Name:MARKS, GLENN R (PHD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:MARKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N TUCSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4745
Mailing Address - Country:US
Mailing Address - Phone:520-299-4806
Mailing Address - Fax:520-323-3739
Practice Address - Street 1:4750 N CAMINO LUZ
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5819
Practice Address - Country:US
Practice Address - Phone:520-299-4806
Practice Address - Fax:520-323-3739
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3558103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ75774Medicare PIN