Provider Demographics
NPI:1801588058
Name:GLASS, GEORGENE TANEISHA (CHW)
Entity type:Individual
Prefix:
First Name:GEORGENE
Middle Name:TANEISHA
Last Name:GLASS
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6821 GREENSMEN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-3788
Mailing Address - Country:US
Mailing Address - Phone:702-723-2286
Mailing Address - Fax:
Practice Address - Street 1:8352 W WARM SPRINGS RD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-3629
Practice Address - Country:US
Practice Address - Phone:702-330-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health