Provider Demographics
NPI:1952067720
Name:GLASS, SHIRAN (LMSW)
Entity Type:Individual
Prefix:
First Name:SHIRAN
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BAKER CT UNIT 115
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558-2272
Mailing Address - Country:US
Mailing Address - Phone:516-477-6882
Mailing Address - Fax:
Practice Address - Street 1:191 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2790
Practice Address - Country:US
Practice Address - Phone:631-264-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114837104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker