Provider Demographics
NPI:1760734164
Name:GLASSFORD, ALICIA B (LD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:B
Last Name:GLASSFORD
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3385
Mailing Address - Country:US
Mailing Address - Phone:770-339-1387
Mailing Address - Fax:770-962-7868
Practice Address - Street 1:758 OLD NORCROSS RD
Practice Address - Street 2:SUITE 175
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3385
Practice Address - Country:US
Practice Address - Phone:770-339-1387
Practice Address - Fax:770-962-7868
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002945133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered