Provider Demographics
NPI:1679286082
Name:GLASSCOCK, THREASA LYNN
Entity Type:Individual
Prefix:
First Name:THREASA
Middle Name:LYNN
Last Name:GLASSCOCK
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 1:3001 ALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3752
Mailing Address - Country:US
Mailing Address - Phone:407-973-4210
Mailing Address - Fax:
Practice Address - Street 1:3001 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3752
Practice Address - Country:US
Practice Address - Phone:407-973-4210
Practice Address - Fax:321-332-0619
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1248103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool