Provider Demographics
NPI:1093855892
Name:GLASS AND HENRY PC
Entity Type:Organization
Organization Name:GLASS AND HENRY PC
Other - Org Name:T A LARKSPUR PSYCHOTHERAPHY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-497-4965
Mailing Address - Street 1:505 S INDEPENDENCE BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1150
Mailing Address - Country:US
Mailing Address - Phone:757-497-4965
Mailing Address - Fax:757-497-4197
Practice Address - Street 1:505 S INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1150
Practice Address - Country:US
Practice Address - Phone:757-497-4965
Practice Address - Fax:757-497-4197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040032821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A000899OtherVALUE OPTIONS
344120OtherTRICARE
VAC02888Medicare PIN