MEDICARE: ELENA GLASS MA, NCC

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	101YM0800X	Mental Health Counselor	0105306	CO

General Provider Information

NPI Number	:	1821441007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELENA GLASS MA, NCC

Provider Business Mailing Address
First Line	:	6760 CORPORATE DR
Second Line	:	ST 140
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-1985
Country	:	US
Telephone Number	:	757-839-8530
Fax Number	:

Provider Business Practice Location Address
First Line	:	6760 CORPORATE DR
Second Line	:	ST 140
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-1985
Country	:	US
Telephone Number	:	757-839-8530
Fax Number	:

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

Provider Enumeration Date	:	07/22/2016
Last Update Date	:	07/22/2016

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