Provider Demographics
NPI:1255346078
Name:GLASS, PAUL KENNETH (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:KENNETH
Last Name:GLASS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2717 N GRANDVIEW BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1660
Mailing Address - Country:US
Mailing Address - Phone:262-544-6486
Mailing Address - Fax:
Practice Address - Street 1:2717 N GRANDVIEW BLVD
Practice Address - Street 2:STE. 303
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1672
Practice Address - Country:US
Practice Address - Phone:262-544-6486
Practice Address - Fax:262-544-6377
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI797-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39018500Medicaid
WI84154-0004Medicare ID - Type UnspecifiedPSYCHOLOGY