Provider Demographics
NPI:1346463965
Name:GLOWICKI, SALLY JANE (MA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JANE
Last Name:GLOWICKI
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 1:214 BUSH RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-3179
Mailing Address - Country:US
Mailing Address - Phone:434-392-7049
Mailing Address - Fax:434-392-9221
Practice Address - Street 1:214 BUSH RIVER DR
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-3179
Practice Address - Country:US
Practice Address - Phone:434-392-7049
Practice Address - Fax:434-392-9221
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013113103T00000X
VA0701006136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945450Medicaid