Provider Demographics
NPI:1487108742
Name:SARGENT, GLEN RYAN (MSED, LPCC)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:RYAN
Last Name:SARGENT
Suffix:
Gender:M
Credentials:MSED, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 RUSKIN DR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1359
Mailing Address - Country:US
Mailing Address - Phone:614-551-0370
Mailing Address - Fax:
Practice Address - Street 1:880 RUSKIN DR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1359
Practice Address - Country:US
Practice Address - Phone:614-551-0370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2022-03-30
Deactivation Date:2021-11-26
Deactivation Code:
Reactivation Date:2022-03-30
Provider Licenses
StateLicense IDTaxonomies
OHE.1901524101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid