MEDICARE: DR. CHARLES D. GLASS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	3088	CO

General Provider Information

NPI Number	:	1265425565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES D. GLASS PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 3850
Second Line	:
City	:	BRECKENRIDGE
State	:	CO
Zip	:	80424-3850
Country	:	US
Telephone Number	:	970-453-5200
Fax Number	:	970-453-8900

Provider Business Practice Location Address
First Line	:	424 SOUTH RIDGE STREET
Second Line	:
City	:	BRECKENRIDGE
State	:	CO
Zip	:	80424-3850
Country	:	US
Telephone Number	:	970-453-5200
Fax Number	:	970-453-8900

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	09/16/2008

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