Provider Demographics
NPI:1518179035
Name:GLASS, LYDIA S (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:S
Last Name:GLASS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E. DEL MAR BLVD.
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:626-792-4153
Mailing Address - Fax:626-930-0626
Practice Address - Street 1:200 E. DEL MAR BLVD.
Practice Address - Street 2:SUITE 210
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105
Practice Address - Country:US
Practice Address - Phone:626-792-4153
Practice Address - Fax:626-930-0626
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13464101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR16694Medicare UPIN