Provider Demographics
NPI:1275147126
Name:GLASS, GERALD A (LLBSW, CADC-DP)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:A
Last Name:GLASS
Suffix:
Gender:M
Credentials:LLBSW, CADC-DP
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLBSW, CADC-DP
Mailing Address - Street 1:120 S MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1975
Mailing Address - Country:US
Mailing Address - Phone:248-529-6383
Mailing Address - Fax:866-250-6455
Practice Address - Street 1:120 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1975
Practice Address - Country:US
Practice Address - Phone:248-529-6383
Practice Address - Fax:866-250-6455
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020909611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical