Provider Demographics
NPI:1649380569
Name:GLASS, DANIEL JOSEPH (MS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:GLASS
Suffix:
Gender:M
Credentials:MS
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 205
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-0205
Mailing Address - Country:US
Mailing Address - Phone:505-585-2534
Mailing Address - Fax:
Practice Address - Street 1:101 SAGE AVE
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340-0210
Practice Address - Country:US
Practice Address - Phone:505-464-4441
Practice Address - Fax:505-464-4814
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0244101YP2500X
NM0244228513101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool