Provider Demographics
NPI:1356128383
Name:GLAZE, CAITLIN ELIZABETH
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ELIZABETH
Last Name:GLAZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 WINDING RD APT 6301
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-1186
Mailing Address - Country:US
Mailing Address - Phone:719-644-9965
Mailing Address - Fax:
Practice Address - Street 1:10545 COLERAIN RD
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3720
Practice Address - Country:US
Practice Address - Phone:912-266-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician