Provider Demographics
NPI:1598966459
Name:STIDHAM, GLENDA SUE (IECE CERTIFIED)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:SUE
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:IECE CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-5714
Mailing Address - Country:US
Mailing Address - Phone:606-598-2815
Mailing Address - Fax:606-598-0148
Practice Address - Street 1:57 MILLER RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-5714
Practice Address - Country:US
Practice Address - Phone:606-598-2815
Practice Address - Fax:606-598-0148
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY01984261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01984OtherDEVELOPMENTAL INTERVENTIO