Provider Demographics
NPI:1104464296
Name:GLAZE, CHRISTOPHER BLAKE
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:BLAKE
Last Name:GLAZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LANETT
Mailing Address - State:AL
Mailing Address - Zip Code:36863-2831
Mailing Address - Country:US
Mailing Address - Phone:706-590-2839
Mailing Address - Fax:
Practice Address - Street 1:122 GORDON COMMERCIAL DR STE C
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5754
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional