Provider Demographics
NPI:1871755579
Name:GLENN R CADDY PHD PA
Entity type:Organization
Organization Name:GLENN R CADDY PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:CADDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-565-8850
Mailing Address - Street 1:3101 N FEDERAL HWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1018
Mailing Address - Country:US
Mailing Address - Phone:954-565-8850
Mailing Address - Fax:
Practice Address - Street 1:3101 N FEDERAL HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1018
Practice Address - Country:US
Practice Address - Phone:954-565-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2093261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health