Provider Demographics
NPI:1972882447
Name:GLAZ, MICHAEL (MS, CASAC-T)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GLAZ
Suffix:
Gender:M
Credentials:MS, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230060
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-0060
Mailing Address - Country:US
Mailing Address - Phone:866-569-7233
Mailing Address - Fax:718-336-6815
Practice Address - Street 1:255 AVENUE W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5202
Practice Address - Country:US
Practice Address - Phone:866-569-7233
Practice Address - Fax:718-336-6815
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25563101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor