Provider Demographics
NPI:1720570914
Name:GLANTZ, AMBER DANIELLE
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:DANIELLE
Last Name:GLANTZ
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 1:2621 NE 131ST CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6428
Mailing Address - Country:US
Mailing Address - Phone:925-813-4823
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6875
Practice Address - Country:US
Practice Address - Phone:971-236-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXEH903730019OtherBLUE SHEILD