Provider Demographics
NPI:1417605031
Name:AUDREY GLAIZE, LLC
Entity Type:Organization
Organization Name:AUDREY GLAIZE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:502-655-4403
Mailing Address - Street 1:409 MARQUETTE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4719
Mailing Address - Country:US
Mailing Address - Phone:502-785-5200
Mailing Address - Fax:
Practice Address - Street 1:409 MARQUETTE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4719
Practice Address - Country:US
Practice Address - Phone:502-785-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty