Provider Demographics
NPI:1942780051
Name:GLIDEWELL, SAMANTHA DIANE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DIANE
Last Name:GLIDEWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5171 RED CLOUD CT APT 3
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-9539
Mailing Address - Country:US
Mailing Address - Phone:469-215-4596
Mailing Address - Fax:
Practice Address - Street 1:311 ALBERT SABIN WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-2838
Practice Address - Country:US
Practice Address - Phone:513-558-5821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OH103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician