Basic Information
| Provider Information | |||||||||
| NPI: | 1407580400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | KENNEDY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 248 EXECUTIVE PARK DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 E CARDINAL ST | ||||||||
| Address2: | |||||||||
| City: | SILER CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273443300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196632955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2022 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P017726 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | LCAS-28246 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.