Provider Demographics
NPI:1003210832
Name:GLASSFORD, LISA ANN (BCBA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:GLASSFORD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:397 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-1519
Mailing Address - Country:US
Mailing Address - Phone:732-604-4762
Mailing Address - Fax:
Practice Address - Street 1:397 N LAKE DR
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-1519
Practice Address - Country:US
Practice Address - Phone:732-604-4762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst