Provider Demographics
NPI:1265425565
Name:GLASS, CHARLES D (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:GLASS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3850
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-3850
Mailing Address - Country:US
Mailing Address - Phone:970-453-5200
Mailing Address - Fax:970-453-8900
Practice Address - Street 1:424 SOUTH RIDGE STREET
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424-3850
Practice Address - Country:US
Practice Address - Phone:970-453-5200
Practice Address - Fax:970-453-8900
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3088103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist