Provider Demographics
NPI:1689213191
Name:GLASS, STEPHANIE ANN (CDCA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:GLASS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3817 LUXAIR DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-1562
Mailing Address - Country:US
Mailing Address - Phone:614-364-3310
Mailing Address - Fax:
Practice Address - Street 1:3817 LUXAIR DR
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-1562
Practice Address - Country:US
Practice Address - Phone:614-364-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171990101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)