Provider Demographics
NPI:1265565972
Name:GLASS, ANNETTE ELLEN (LMFT)
Entity type:Individual
Prefix:MISS
First Name:ANNETTE
Middle Name:ELLEN
Last Name:GLASS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5991
Mailing Address - Country:US
Mailing Address - Phone:831-236-2060
Mailing Address - Fax:
Practice Address - Street 1:236 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5991
Practice Address - Country:US
Practice Address - Phone:831-236-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46771106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist