Healthcare Provider Details

I. General information

NPI: 1740964972
Provider Name (Legal Business Name): GLOW SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W HOPKINS ST
MILWAUKEE WI
53206-1749
US

IV. Provider business mailing address

PO BOX 91352
MILWAUKEE WI
53209-8352
US

V. Phone/Fax

Practice location:
  • Phone: 414-218-1001
  • Fax:
Mailing address:
  • Phone: 414-628-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICKELL DANIELS
Title or Position: CEO/LEAD THERAPIST
Credential:
Phone: 414-628-0112