Provider Demographics
NPI:1396610259
Name:GLENN, AUTUMN NICOLE (BCBA)
Entity type:Individual
Prefix:MISS
First Name:AUTUMN
Middle Name:NICOLE
Last Name:GLENN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N MILLER RD STE 150A
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3713
Mailing Address - Country:US
Mailing Address - Phone:330-867-2240
Mailing Address - Fax:
Practice Address - Street 1:150 N MILLER RD STE 150A
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3713
Practice Address - Country:US
Practice Address - Phone:330-867-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-25-82172103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst