Provider Demographics
NPI:1083227862
Name:GLASCO, DYLAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:GLASCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BAIRD CT
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-5104
Mailing Address - Country:US
Mailing Address - Phone:918-429-5424
Mailing Address - Fax:
Practice Address - Street 1:103 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4043
Practice Address - Country:US
Practice Address - Phone:918-465-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor