Provider Demographics
NPI:1578161824
Name:GLASS, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
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 1:8526 HUNTSMAN LN
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5226 HARBINGER RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-2046
Practice Address - Country:US
Practice Address - Phone:724-766-9405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-138850106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician