Basic Information
Provider Information
NPI: 1003141458
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GLIDEWELL
FirstName: SUZANNE
MiddleName: JANE
NamePrefix:  
NameSuffix:  
Credential: MSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: SPENCER
OtherFirstName: SUZANNE
OtherMiddleName: JANE
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MSW
OtherLastNameType: 1
Mailing Information
Address1: 9343 TECH CENTER DR
Address2: SECOND FLOOR
City: SACRAMENTO
State: CA
PostalCode: 958262563
CountryCode: US
TelephoneNumber: 9163886397
FaxNumber: 9168759970
Practice Location
Address1: 9343 TECH CENTER DR
Address2: SECOND FLOOR
City: SACRAMENTO
State: CA
PostalCode: 958262563
CountryCode: US
TelephoneNumber: 9163886397
FaxNumber: 9168759970
Other Information
ProviderEnumerationDate: 10/02/2009
LastUpdateDate: 03/09/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X26687CAY Behavioral Health & Social Service ProvidersSocial Worker 
1041C0700X26687CAN Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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