Provider Demographics
NPI:1871810903
Name:GLENN, CRYSTAL ELAINE (MA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELAINE
Last Name:GLENN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912B BEAVER TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6602
Mailing Address - Country:US
Mailing Address - Phone:512-659-7818
Mailing Address - Fax:
Practice Address - Street 1:912B BEAVER TRL
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6602
Practice Address - Country:US
Practice Address - Phone:512-659-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64471101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional