Provider Demographics
NPI:1710485867
Name:GLASS, ALEXIS KYRSTEN
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:KYRSTEN
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 1:780 FASHION DR APT 5302
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-5724
Mailing Address - Country:US
Mailing Address - Phone:717-668-7823
Mailing Address - Fax:
Practice Address - Street 1:140 W FRANKLIN ST STE 202
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940
Practice Address - Country:US
Practice Address - Phone:800-991-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB391208106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician