Healthcare Provider Details

I. General information

NPI: 1275476541
Provider Name (Legal Business Name): SHANE GLATZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11172 ADAMS ST
HOLLAND MI
49423-9163
US

IV. Provider business mailing address

11172 ADAMS ST
HOLLAND MI
49423-9163
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2522
  • Fax:
Mailing address:
  • Phone: 616-942-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: