Provider Demographics
NPI:1316515216
Name:GLASS, SHILLEAH IDORA
Entity type:Individual
Prefix:MRS
First Name:SHILLEAH
Middle Name:IDORA
Last Name:GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHILLEAH
Other - Middle Name:IDORA
Other - Last Name:FLAVIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:520 DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2769
Mailing Address - Country:US
Mailing Address - Phone:857-249-3112
Mailing Address - Fax:
Practice Address - Street 1:520 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-2769
Practice Address - Country:US
Practice Address - Phone:617-438-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator