Provider Demographics
NPI:1912170606
Name:GLAZE, DORIAN L (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:L
Last Name:GLAZE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-1238
Mailing Address - Country:US
Mailing Address - Phone:715-236-6408
Mailing Address - Fax:715-236-6588
Practice Address - Street 1:1100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1238
Practice Address - Country:US
Practice Address - Phone:715-236-6408
Practice Address - Fax:715-236-6588
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2379-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42797400Medicaid