Provider Demographics
NPI:1548247968
Name:GLAZA, THOMAS GEORGE (MA, M ED)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GEORGE
Last Name:GLAZA
Suffix:
Gender:M
Credentials:MA, M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2763 S SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-8266
Mailing Address - Country:US
Mailing Address - Phone:941-426-7608
Mailing Address - Fax:
Practice Address - Street 1:12497 TAMIAMI TRL S
Practice Address - Street 2:SUITE #9
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-1447
Practice Address - Country:US
Practice Address - Phone:941-429-0804
Practice Address - Fax:941-429-0814
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2188101YA0400X
FLMH5146101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2188OtherCAP CERTIFICATE
FLMH5146OtherSTATE LICENSE