Basic Information
| Provider Information | |||||||||
| NPI: | 1215685615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | COLLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JEFFERSON ST STE 2C | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245041724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552847483 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 COUNTRY CLUB PKWY STE A | ||||||||
| Address2: | |||||||||
| City: | MAUMELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721137048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552847483 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2022 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 202198 | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.