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General NPI Number Information
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NPI Number | 1790887206
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Entity Type | Individual
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Provider Name | ELIZABETH RAY GLAZE LPC
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Gender | Female
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Dates
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Enumeration Date | 09/04/2006
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Last Update Date | 06/16/2021
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Provider Practice Location Address
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Address Line | 1105 FURYS LN STE D
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City | MARTINEZ
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State | GA
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Zip | 30907-8238
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Country | US
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Telephone | 706-288-5082
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Fax | 706-863-0941
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Provider Business Mailing Address
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Address Line | PO BOX 238
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City | APPLING
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State | GA
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Zip | 30802-0238
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Country | US
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Telephone | 706-288-5082
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Fax | 706-863-0941
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC003774
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License Number State | GA
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