Provider Demographics
NPI:1659861201
Name:GLASS, AMY BETH
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:BETH
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 1:7385 SHADY PALM DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-1837
Mailing Address - Country:US
Mailing Address - Phone:402-210-5226
Mailing Address - Fax:
Practice Address - Street 1:2110 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-5719
Practice Address - Country:US
Practice Address - Phone:703-228-6065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000962103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool