Provider Demographics
NPI:1790992071
Name:GLAZE, RUTH LAIL
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:LAIL
Last Name:GLAZE
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 1:207 W. LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4430
Mailing Address - Country:US
Mailing Address - Phone:601-924-1813
Mailing Address - Fax:
Practice Address - Street 1:2508 LAKELAND DR STE 200
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9502
Practice Address - Country:US
Practice Address - Phone:601-664-0455
Practice Address - Fax:601-664-1675
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0188101YP2500X
MST0002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist