Healthcare Provider Details

I. General information

NPI: 1598035271
Provider Name (Legal Business Name): SARAH A GLAZE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS SARAH A KING

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15655 COUNTY ROAD B
HAYWARD WI
54843-3251
US

IV. Provider business mailing address

15655 COUNTY ROAD B P.O, BOX 13251
HAYWARD WI
54843-3251
US

V. Phone/Fax

Practice location:
  • Phone: 715-634-0607
  • Fax: 715-634-0617
Mailing address:
  • Phone: 715-634-0607
  • Fax: 717-634-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: