Basic Information
| Provider Information | |||||||||
| NPI: | 1255302774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLASS MENTAL HEALTH FOUNDATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 401 E CORPORATE DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143793347 | ||||||||
| FaxNumber: | 2143793324 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 W AYLESBURY RD | ||||||||
| Address2: | |||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105619591 | ||||||||
| FaxNumber: | 4105601082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDREWS | ||||||||
| AuthorizedOfficialFirstName: | BOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 2143793398 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GLASS MENTAL HEALTH FOUNDATION, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 13110 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | 905032 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR0405X | 905032 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM2800X | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 99241900 | 05 | MD | MEDICAID | 099421900 | 05 | MD | MEDICAID |