Provider Demographics
NPI:1174217764
Name:GLAZE, XIOMARA
Entity type:Individual
Prefix:
First Name:XIOMARA
Middle Name:
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 1:12300 ROCK HILL RD #3411
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12300 ROCK HILL RD #3411
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1308
Practice Address - Country:US
Practice Address - Phone:516-508-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011846101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional