Provider Demographics
NPI:1366565954
Name:LYNESSA GLASS, INC.
Entity type:Organization
Organization Name:LYNESSA GLASS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC LMFT
Authorized Official - Phone:757-717-0605
Mailing Address - Street 1:4356 BONNEY RD
Mailing Address - Street 2:BUILDING 1, SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1200
Mailing Address - Country:US
Mailing Address - Phone:757-717-0605
Mailing Address - Fax:757-498-3311
Practice Address - Street 1:4356 BONNEY RD
Practice Address - Street 2:BUILDING 1, SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1200
Practice Address - Country:US
Practice Address - Phone:757-717-0605
Practice Address - Fax:757-498-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717000634106H00000X
VA0701002709101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty