Healthcare Provider Details

I. General information

NPI: 1174433056
Provider Name (Legal Business Name): ALICIA GLASS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4708 GREEN RIVER CT NE
MARIETTA GA
30068-4869
US

IV. Provider business mailing address

4708 GREEN RIVER CT NE
MARIETTA GA
30068-4869
US

V. Phone/Fax

Practice location:
  • Phone: 719-338-5528
  • Fax:
Mailing address:
  • Phone: 719-338-5528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License NumberLD005449
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: