Provider Demographics
NPI:1407229669
Name:GLASCO, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GLASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GLASCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSHS, RSST
Mailing Address - Street 1:20010 FORRER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1822
Mailing Address - Country:US
Mailing Address - Phone:248-910-4651
Mailing Address - Fax:
Practice Address - Street 1:20010 FORRER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1822
Practice Address - Country:US
Practice Address - Phone:248-910-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086580104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6803086580Medicaid