=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811881089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMETT BLAY GLASBRENNER LMSW, LCDC-I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2025
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 LADY BIRD LN
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-495-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3705 LAKEVIEW PKWY STE 301
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75088-4179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-319-8706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 72986
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 114704
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------