Provider Demographics
NPI:1740992916
Name:GLENN, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GLENN
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 1:225 MAIN ST APT 309
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2729
Mailing Address - Country:US
Mailing Address - Phone:920-289-0638
Mailing Address - Fax:
Practice Address - Street 1:505 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7949
Practice Address - Country:US
Practice Address - Phone:920-232-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)