Provider Demographics
NPI:1184768103
Name:GLAZE, ELLEN MARIE (MS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:GLAZE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARIE MAYFIELD
Other - Last Name:GLAZE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA
Mailing Address - Street 1:1515 MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-4357
Mailing Address - Country:US
Mailing Address - Phone:510-232-7571
Mailing Address - Fax:510-235-2545
Practice Address - Street 1:1515 MARKET AVE
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-4357
Practice Address - Country:US
Practice Address - Phone:510-232-7571
Practice Address - Fax:510-235-2545
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)