Provider Demographics
NPI:1548821242
Name:GLASS, MELISSA (MA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3563 S STATE ROAD 13
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-9162
Mailing Address - Country:US
Mailing Address - Phone:260-563-8453
Mailing Address - Fax:
Practice Address - Street 1:3565 S STATE ROAD 13
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-9162
Practice Address - Country:US
Practice Address - Phone:260-563-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN39004821A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor