Provider Demographics
NPI:1588072789
Name:STANTON, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:STANTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6532 SANDPEBBLE CT
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-3626
Mailing Address - Country:US
Mailing Address - Phone:937-305-8289
Mailing Address - Fax:
Practice Address - Street 1:6532 SANDPEBBLE CT
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-3626
Practice Address - Country:US
Practice Address - Phone:937-305-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH060189101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)