Healthcare Provider Details

I. General information

NPI: 1053785659
Provider Name (Legal Business Name): TABITHA GLENN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5537 VICKSBURG DR
INDIANAPOLIS IN
46254-5036
US

IV. Provider business mailing address

5537 VICKSBURG DR
INDIANAPOLIS IN
46254-5036
US

V. Phone/Fax

Practice location:
  • Phone: 317-296-4842
  • Fax:
Mailing address:
  • Phone: 317-296-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: