Provider Demographics
NPI:1568674711
Name:GLASS, EUGENE RICHARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:RICHARD
Last Name:GLASS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401
Mailing Address - Country:US
Mailing Address - Phone:712-792-5931
Mailing Address - Fax:
Practice Address - Street 1:317 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401
Practice Address - Country:US
Practice Address - Phone:712-792-5931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA642103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical