=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255302774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLASS MENTAL HEALTH FOUNDATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2006
-----------------------------------------------------
Last Update Date | 10/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 W AYLESBURY RD
-----------------------------------------------------
City | TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-4101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-561-9591
-----------------------------------------------------
Fax | 410-560-1082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E CORPORATE DR SUITE 220
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75057-6430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-379-3347
-----------------------------------------------------
Fax | 214-379-3324
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, REVENUE CYCLE
-----------------------------------------------------
Name | BOND ANDREWS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-379-3398
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 13110
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 905032
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 905032
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM2800X
-----------------------------------------------------
Taxonomy Name | Methadone Clinic
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------