Provider Demographics
NPI:1700200599
Name:GLASSMAN, KYLE TIMOTHY
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:TIMOTHY
Last Name:GLASSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 FM 1488 RD APT 1347
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3921
Mailing Address - Country:US
Mailing Address - Phone:530-219-4242
Mailing Address - Fax:
Practice Address - Street 1:245 FM 1488 RD APT 1347
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-3921
Practice Address - Country:US
Practice Address - Phone:530-219-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124129106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist