Provider Demographics
NPI:1487201711
Name:GLENN, SUSAN D (MA, BCBA, COBA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:D
Last Name:GLENN
Suffix:
Gender:F
Credentials:MA, BCBA, COBA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA, COBA
Mailing Address - Street 1:23220 CHAGRIN BLVD APT 140
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5421
Mailing Address - Country:US
Mailing Address - Phone:317-225-9119
Mailing Address - Fax:
Practice Address - Street 1:22600 ASCOA CT
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44149-4700
Practice Address - Country:US
Practice Address - Phone:440-870-2122
Practice Address - Fax:216-208-1475
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-22-58206103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst