Provider Demographics
NPI:1770193682
Name:GLASS, VICTORIA ANNE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANNE
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 1:4166 TAMARACK TURN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1923
Mailing Address - Country:US
Mailing Address - Phone:231-633-0876
Mailing Address - Fax:
Practice Address - Street 1:5281 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9506
Practice Address - Country:US
Practice Address - Phone:616-719-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician