Healthcare Provider Details

I. General information

NPI: 1306385844
Provider Name (Legal Business Name): GLORIS GRIFFIN LPCC-SUPV, LICDC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 MARKET ST STE 203
BOARDMAN OH
44512-2624
US

IV. Provider business mailing address

5500 MARKET ST STE 203
BOARDMAN OH
44512-2624
US

V. Phone/Fax

Practice location:
  • Phone: 330-330-8332
  • Fax:
Mailing address:
  • Phone: 330-330-8332
  • Fax: 330-330-8332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161866
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1901297
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: