Healthcare Provider Details

I. General information

NPI: 1518362565
Provider Name (Legal Business Name): GARY GLASS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2014
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CLAIREMONT AVE STE 500
DECATUR GA
30030-2560
US

IV. Provider business mailing address

1377 MILTON PL SE
ATLANTA GA
30316-2019
US

V. Phone/Fax

Practice location:
  • Phone: 919-490-1952
  • Fax:
Mailing address:
  • Phone: 919-490-1952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY002645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: