Provider Demographics
NPI:1699589424
Name:GLASS, ELISABETH (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:GLASS
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 BLUE SPRUCE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9189
Mailing Address - Country:US
Mailing Address - Phone:573-814-9841
Mailing Address - Fax:
Practice Address - Street 1:5105 BLUE SPRUCE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-9189
Practice Address - Country:US
Practice Address - Phone:573-814-9841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023037484133V00000X
MO86292633133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered