Basic Information
| Provider Information | |||||||||
| NPI: | 1740702828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASKOX | ||||||||
| FirstName: | MIRRANDA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 COOK RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5137252231 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 GREENWOOD LN | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450663033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377468523 | ||||||||
| FaxNumber: | 9377467857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RA.161588 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | C.1901743-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.