Provider Demographics
NPI:1164558318
Name:GLENN, MARY LEONORA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LEONORA
Last Name:GLENN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PARK LN
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2906
Mailing Address - Country:US
Mailing Address - Phone:617-524-7290
Mailing Address - Fax:617-524-7290
Practice Address - Street 1:256 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1337
Practice Address - Country:US
Practice Address - Phone:617-864-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6462103TA0700X, 103TC0700X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO5206OtherBLUECROSSBLUESHIELD