Provider Demographics
NPI:1093381436
Name:GLASS, EMILY LAUREN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:LAUREN
Last Name:GLASS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:LAUREN
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:3711 USF CITRUS DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-974-9844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13927235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY911WOtherBLUE CROSS BLUE SHIELD
FL110702400Medicaid