Healthcare Provider Details

I. General information

NPI: 1083509046
Provider Name (Legal Business Name): GLOW BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3712 ISLA VISTA CT
MADERA CA
93637-3314
US

IV. Provider business mailing address

8605 SANTA MONICA BLVD # 552856
WEST HOLLYWOOD CA
90069-4109
US

V. Phone/Fax

Practice location:
  • Phone: 559-975-3299
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAYLEIGH RIDER
Title or Position: FOUNDER
Credential:
Phone: 866-559-4569