Provider Demographics
NPI:1912283508
Name:ELIZABETH R. GLAZE, LPC, LLC
Entity Type:Organization
Organization Name:ELIZABETH R. GLAZE, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:GLAZE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-288-5082
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:APPLING
Mailing Address - State:GA
Mailing Address - Zip Code:30802-0238
Mailing Address - Country:US
Mailing Address - Phone:706-288-5082
Mailing Address - Fax:706-863-0941
Practice Address - Street 1:1285 MARKS CHURCH RD STE B
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2472
Practice Address - Country:US
Practice Address - Phone:706-288-5082
Practice Address - Fax:706-863-0941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003774101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty