Provider Demographics
NPI:1437622073
Name:GLASS, DAVID ROGER JR (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ROGER
Last Name:GLASS
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 FORT MYER DR STE 350
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22209-3118
Mailing Address - Country:US
Mailing Address - Phone:703-527-9482
Mailing Address - Fax:
Practice Address - Street 1:1655 FORT MYER DR STE 350
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22209-3118
Practice Address - Country:US
Practice Address - Phone:703-527-9482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000928103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical