Provider Demographics
NPI:1043503022
Name:KATES-GLASS, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:KATES-GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 DESTINY LN
Mailing Address - Street 2:SUITE 112
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1087
Mailing Address - Country:US
Mailing Address - Phone:270-392-5531
Mailing Address - Fax:270-393-9011
Practice Address - Street 1:1830 DESTINY LN
Practice Address - Street 2:SUITE 112
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1087
Practice Address - Country:US
Practice Address - Phone:270-392-5531
Practice Address - Fax:270-393-9011
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical