Basic Information
| Provider Information | |||||||||
| NPI: | 1003945163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOOD | ||||||||
| OtherFirstName: | RENEE | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 49590 NORTH DR | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345607931 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5958 N CANTON CENTER RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481872765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347371200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802059052 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801097175 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251S00000X | 6802059052 | MI | N | Agencies | Community/Behavioral Health | 1041C0700X | 6801097176 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.