Provider Demographics
NPI:1518362565
Name:GLASS, GARY (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GLASS
Suffix:
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 1:4117 LIVINGSTONE PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5524
Mailing Address - Country:US
Mailing Address - Phone:919-490-1952
Mailing Address - Fax:
Practice Address - Street 1:112 SWIFT AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4883
Practice Address - Country:US
Practice Address - Phone:919-490-1952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-01
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3307103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling