Provider Demographics
NPI:1538852322
Name:GLAZE, KIMBERLY (BS, CHW, CRS)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:GLAZE
Suffix:
Gender:F
Credentials:BS, CHW, CRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 TANGER BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-3597
Mailing Address - Country:US
Mailing Address - Phone:812-558-9016
Mailing Address - Fax:
Practice Address - Street 1:357 TANGER BLVD STE 215
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3597
Practice Address - Country:US
Practice Address - Phone:812-558-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty