Provider Demographics
NPI:1710039870
Name:GLASER, BRIAN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:GLASER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 WICKERSHAM DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3182
Mailing Address - Country:US
Mailing Address - Phone:706-254-5214
Mailing Address - Fax:
Practice Address - Street 1:130 WICKERSHAM DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3182
Practice Address - Country:US
Practice Address - Phone:706-254-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1536103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00528657AMedicaid