Provider Demographics
NPI:1326701384
Name:GLASS, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
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 1:1981 PLAZA DR APT 107
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4661 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9301
Practice Address - Country:US
Practice Address - Phone:269-281-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker