Provider Demographics
NPI:1902088990
Name:GLASS, REGINA DIXON
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:DIXON
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 1:11647 HIGHWAY 225 N
Mailing Address - Street 2:
Mailing Address - City:CRANDALL
Mailing Address - State:GA
Mailing Address - Zip Code:30711-6315
Mailing Address - Country:US
Mailing Address - Phone:706-517-8830
Mailing Address - Fax:706-517-0553
Practice Address - Street 1:11647 HIGHWAY 225 N
Practice Address - Street 2:
Practice Address - City:CRANDALL
Practice Address - State:GA
Practice Address - Zip Code:30711-6315
Practice Address - Country:US
Practice Address - Phone:706-517-8830
Practice Address - Fax:706-517-0553
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator