Provider Demographics
NPI:1699349845
Name:GLASS, KALLISON LEE (SLP)
Entity type:Individual
Prefix:
First Name:KALLISON
Middle Name:LEE
Last Name:GLASS
Suffix:
Gender:
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E HARDING ST
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-2047
Mailing Address - Country:US
Mailing Address - Phone:501-697-9881
Mailing Address - Fax:
Practice Address - Street 1:102 E HARDING ST
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-2047
Practice Address - Country:US
Practice Address - Phone:501-697-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist