Provider Demographics
NPI:1134499536
Name:CHERNACK, GLEN MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:MICHAEL
Last Name:CHERNACK
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 1:176 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SLEEPY HOLLOW
Mailing Address - State:NY
Mailing Address - Zip Code:10591-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-2606
Practice Address - Country:US
Practice Address - Phone:718-813-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool