Provider Demographics
NPI:1235189721
Name:GLASS, AVIVA (PHD)
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5-31 50TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:917-647-9042
Mailing Address - Fax:
Practice Address - Street 1:5-31 50TH AVENUE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:917-647-9042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00016583Medicaid
NY00016583Medicaid