Provider Demographics
NPI:1710198916
Name:GLASS, KIA (OTR)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18930 RAINBOW CT
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4404
Mailing Address - Country:US
Mailing Address - Phone:248-200-8001
Mailing Address - Fax:
Practice Address - Street 1:18930 RAINBOW CT
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-4404
Practice Address - Country:US
Practice Address - Phone:248-200-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004151225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist