Healthcare Provider Details

I. General information

NPI: 1568325819
Provider Name (Legal Business Name): EVANGELINE RILEY GLAZIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 E. CARNEGIE DRIVE SUITE 200
SAN BERNARDINO CA
92408
US

IV. Provider business mailing address

473 E. CARNEGIE DRIVE SUITE 200
SAN BERNARDINO CA
92408
US

V. Phone/Fax

Practice location:
  • Phone: 909-453-3103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: