Provider Demographics
NPI:1053726190
Name:GLADE STREET BAPTIST CHURCH
Entity type:Organization
Organization Name:GLADE STREET BAPTIST CHURCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PASTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:HERBERT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD-COUNSELING/PHD-P
Authorized Official - Phone:972-480-4516
Mailing Address - Street 1:500 W. UNIVERSITY DR.
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069
Mailing Address - Country:US
Mailing Address - Phone:972-480-4516
Mailing Address - Fax:
Practice Address - Street 1:500 W. UNIVERSITY DR.
Practice Address - Street 2:SUITE 112
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069
Practice Address - Country:US
Practice Address - Phone:972-480-4516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty