Provider Demographics
NPI:1063874493
Name:GLASS, KELSEY (BCBA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13142 MAPLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3628
Mailing Address - Country:US
Mailing Address - Phone:210-382-0890
Mailing Address - Fax:
Practice Address - Street 1:13142 MAPLE PARK DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3628
Practice Address - Country:US
Practice Address - Phone:210-382-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-16-21472103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1-16-21472OtherBOARD CERTIFIED BEHAVIOR ANALYST