Provider Demographics
NPI:1366899247
Name:GLASS-WOOTEN, LUCRETIA
Entity type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:
Last Name:GLASS-WOOTEN
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:PO BOX 4532
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-0532
Mailing Address - Country:US
Mailing Address - Phone:252-937-3016
Mailing Address - Fax:252-937-3017
Practice Address - Street 1:209 N PEARL ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5426
Practice Address - Country:US
Practice Address - Phone:252-937-3016
Practice Address - Fax:252-937-3017
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)