Provider Demographics
NPI:1891561429
Name:MANCILLA, GLENDA (LMSW)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:MANCILLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:
Other - Last Name:MANCILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:470 W BROAD ST # 1148
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-2759
Mailing Address - Country:US
Mailing Address - Phone:614-542-7463
Mailing Address - Fax:
Practice Address - Street 1:470 W BROAD ST # 1148
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2759
Practice Address - Country:US
Practice Address - Phone:614-542-7463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2310151104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker