Provider Demographics
NPI:1760092019
Name:GLAZE PARKER, MICHELLE WRAYANNE (LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:WRAYANNE
Last Name:GLAZE PARKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 GOLD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TALLAPOOSA
Mailing Address - State:GA
Mailing Address - Zip Code:30176-4339
Mailing Address - Country:US
Mailing Address - Phone:404-372-2885
Mailing Address - Fax:
Practice Address - Street 1:700 CHURCHILL CT STE 110
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6880
Practice Address - Country:US
Practice Address - Phone:770-284-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA509931101YA0400X
GALPC011567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)