Healthcare Provider Details

I. General information

NPI: 1225954241
Provider Name (Legal Business Name): TIM GLASS APCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10877 CONDUCTOR BLVD STE 300
SUTTER CREEK CA
95685-9688
US

IV. Provider business mailing address

10877 CONDUCTOR BLVD STE 300
SUTTER CREEK CA
95685-9688
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-6412
  • Fax: 209-223-0980
Mailing address:
  • Phone: 209-223-6412
  • Fax: 209-223-0980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22796
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: