Provider Demographics
NPI:1558057778
Name:GLOVER, FANTAZIA M
Entity Type:Individual
Prefix:
First Name:FANTAZIA
Middle Name:M
Last Name:GLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 33RD PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2910
Mailing Address - Country:US
Mailing Address - Phone:202-704-1384
Mailing Address - Fax:
Practice Address - Street 1:1215 33RD PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2910
Practice Address - Country:US
Practice Address - Phone:202-704-1384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician