Provider Demographics
NPI:1447564869
Name:SMITH, GLENN DOUGLAS (MS, LPCC, LADC)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, LPCC, LADC
Other - Prefix:
Other - First Name:EARL
Other - Middle Name:LEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS,LPCC, LADC
Mailing Address - Street 1:1313 PENN AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-3047
Mailing Address - Country:US
Mailing Address - Phone:763-746-6553
Mailing Address - Fax:612-302-4872
Practice Address - Street 1:1313 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3047
Practice Address - Country:US
Practice Address - Phone:612-543-3742
Practice Address - Fax:612-302-4872
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41-1303326101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)