Provider Demographics
NPI:1518623255
Name:GLASS, MARAISA SHIRA
Entity Type:Individual
Prefix:
First Name:MARAISA
Middle Name:SHIRA
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 1:843 N HAYWORTH AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-7193
Mailing Address - Country:US
Mailing Address - Phone:310-422-2465
Mailing Address - Fax:
Practice Address - Street 1:840 N AVENUE 66
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1508
Practice Address - Country:US
Practice Address - Phone:310-422-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker