Healthcare Provider Details

I. General information

NPI: 1184617755
Provider Name (Legal Business Name): MITZI K GLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 VOLVO PKWY STE 202
CHESAPEAKE VA
23320-7656
US

IV. Provider business mailing address

760 LYNNHAVEN PKWY STE 201
VIRGINIA BEACH VA
23452-7325
US

V. Phone/Fax

Practice location:
  • Phone: 757-312-8550
  • Fax: 757-312-8553
Mailing address:
  • Phone: 757-306-4232
  • Fax: 757-306-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004491
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: