Provider Demographics
NPI:1114127339
Name:GLASS, CATHY ANNE
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:ANNE
Last Name: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 1:6721 COUNTY ROAD 248
Mailing Address - Street 2:
Mailing Address - City:O BRIEN
Mailing Address - State:FL
Mailing Address - Zip Code:32071-4139
Mailing Address - Country:US
Mailing Address - Phone:386-935-2263
Mailing Address - Fax:386-935-2263
Practice Address - Street 1:6721 COUNTY ROAD 248
Practice Address - Street 2:
Practice Address - City:O BRIEN
Practice Address - State:FL
Practice Address - Zip Code:32071-4139
Practice Address - Country:US
Practice Address - Phone:386-935-2263
Practice Address - Fax:386-935-2263
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811832900Medicaid