Provider Demographics
NPI:1326660242
Name:GLOW ABA LLC
Entity Type:Organization
Organization Name:GLOW ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:804-464-3805
Mailing Address - Street 1:3612 STONEY RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4534
Mailing Address - Country:US
Mailing Address - Phone:804-464-3805
Mailing Address - Fax:
Practice Address - Street 1:3612 STONEY RIDGE TRAIL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4534
Practice Address - Country:US
Practice Address - Phone:804-536-9359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053731448Medicaid