Provider Demographics
NPI:1033766241
Name:GLACKING, STEPHANIE ANN (LICDC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:GLACKING
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:
Practice Address - Street 1:5108 SANDY LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2738
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162433101YA0400X, 101YA0400X
OHLCDCIII.162175101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)