Provider Demographics
NPI:1811595416
Name:GLASS, CARRIE MICHELLE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MICHELLE
Last Name:GLASS
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1160
Mailing Address - Country:US
Mailing Address - Phone:734-508-7036
Mailing Address - Fax:
Practice Address - Street 1:903 DEXTER ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1160
Practice Address - Country:US
Practice Address - Phone:734-508-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501013088172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist