MEDICARE: KRISTIN MARI GLANZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	R1235310716	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R1235310716	OTHER	CA	CCAPP REGISTRATION

General Provider Information

NPI Number	:	1609321934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN MARI GLANZ

Provider Business Mailing Address
First Line	:	256 BUENA VISTA ST
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-7239
Country	:	US
Telephone Number	:	530-274-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	256 BUENA VISTA ST
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-7239
Country	:	US
Telephone Number	:	530-274-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2016
Last Update Date	:	08/16/2016

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Directions to “ KRISTIN MARI GLANZ ” Practice Location

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