Provider Demographics
NPI:1245946078
Name:GLENN, TAIRA S
Entity type:Individual
Prefix:
First Name:TAIRA
Middle Name:S
Last Name:GLENN
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 1:4200 BIXBY RD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9509
Mailing Address - Country:US
Mailing Address - Phone:614-836-9675
Mailing Address - Fax:
Practice Address - Street 1:4200 BIXBY RD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9509
Practice Address - Country:US
Practice Address - Phone:614-836-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging