Provider Demographics
NPI:1487229811
Name:GLASS, BETHANY LEIGH
Entity Type:Individual
Prefix:MISS
First Name:BETHANY
Middle Name:LEIGH
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 1:127 SCOTLAND RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4538
Mailing Address - Country:US
Mailing Address - Phone:601-955-7518
Mailing Address - Fax:
Practice Address - Street 1:6 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4113
Practice Address - Country:US
Practice Address - Phone:601-955-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional