Provider Demographics
NPI:1083105233
Name:GLASS, DEREK JOSEPH (RBT)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JOSEPH
Last Name:GLASS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10503 METRIC DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5514
Mailing Address - Country:US
Mailing Address - Phone:972-644-2076
Mailing Address - Fax:
Practice Address - Street 1:10503 METRIC DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5514
Practice Address - Country:US
Practice Address - Phone:972-644-2076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-55030106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician