Provider Demographics
NPI:1184617755
Name:GLASS, MITZI K
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:K
Last Name:GLASS
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 1:760 LYNNHAVEN PKWY
Mailing Address - Street 2:STE 201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7325
Mailing Address - Country:US
Mailing Address - Phone:757-306-4232
Mailing Address - Fax:757-306-4235
Practice Address - Street 1:1215 VOLVO PKWY
Practice Address - Street 2:STE 202
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-7656
Practice Address - Country:US
Practice Address - Phone:757-312-8550
Practice Address - Fax:757-312-8553
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040044911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8949140Medicaid
VT175778OtherBCBS