Healthcare Provider Details

I. General information

NPI: 1518179035
Provider Name (Legal Business Name): LYDIA S. GLASS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E. DEL MAR BLVD. SUITE 210
PASADENA CA
91105
US

IV. Provider business mailing address

200 E. DEL MAR BLVD. SUITE 210
PASADENA CA
91105
US

V. Phone/Fax

Practice location:
  • Phone: 626-792-4153
  • Fax: 626-930-0626
Mailing address:
  • Phone: 626-792-4153
  • Fax: 626-930-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSY13464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: