Provider Demographics
NPI:1730783010
Name:GLASGOW, CARLA DIANDRE
Entity type:Individual
Prefix:MISS
First Name:CARLA
Middle Name:DIANDRE
Last Name:GLASGOW
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 880591
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-0591
Mailing Address - Country:US
Mailing Address - Phone:239-641-4346
Mailing Address - Fax:
Practice Address - Street 1:8350 MULLIGAN CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3280
Practice Address - Country:US
Practice Address - Phone:239-641-4346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health