Provider Demographics
NPI:1083923205
Name:GLICK, PETER J (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:GLICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL
Mailing Address - Street 2:BOX 1230
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6500
Mailing Address - Country:US
Mailing Address - Phone:212-241-8462
Mailing Address - Fax:
Practice Address - Street 1:51 W 86TH ST
Practice Address - Street 2:SUITE 104D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3613
Practice Address - Country:US
Practice Address - Phone:646-580-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019628103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical