Provider Demographics
NPI:1013124809
Name:GLASS, PHYLLIS ANN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANN
Last Name:GLASS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:PHYLLIS
Other - Middle Name:ANN
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1904 MONROE DR NE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4858
Mailing Address - Country:US
Mailing Address - Phone:404-874-8294
Mailing Address - Fax:404-874-2020
Practice Address - Street 1:1904 MONROE DR NE
Practice Address - Street 2:SUITE 120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-4858
Practice Address - Country:US
Practice Address - Phone:404-874-8294
Practice Address - Fax:404-874-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical