Healthcare Provider Details

I. General information

NPI: 1003945163
Provider Name (Legal Business Name): RENEE S GLASS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENEE SUE WOOD LMSW

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5958 N CANTON CENTER RD
CANTON MI
48187-2765
US

IV. Provider business mailing address

49590 NORTH DR
PLYMOUTH MI
48170-2332
US

V. Phone/Fax

Practice location:
  • Phone: 734-737-1200
  • Fax:
Mailing address:
  • Phone: 734-560-7931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802059052
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097175
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6802059052
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097176
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: