Provider Demographics
NPI:1194594226
Name:GLASS, GREGORY SCOTT (CADC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:GLASS
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BEAGLE CLUB RD
Mailing Address - Street 2:
Mailing Address - City:STONEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27048-7509
Mailing Address - Country:US
Mailing Address - Phone:325-574-0096
Mailing Address - Fax:
Practice Address - Street 1:510 BEAGLE CLUB RD
Practice Address - Street 2:
Practice Address - City:STONEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27048-7509
Practice Address - Country:US
Practice Address - Phone:325-574-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)