Healthcare Provider Details

I. General information

NPI: 1942780051
Provider Name (Legal Business Name): SAMANTHA DIANE GLIDEWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

IV. Provider business mailing address

5171 RED CLOUD CT APT 3
OXFORD OH
45056-9539
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5821
  • Fax:
Mailing address:
  • Phone: 469-215-4596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: