Provider Demographics
NPI:1225109952
Name:GLICK, NICOLE LEIGH SR (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:GLICK
Suffix:SR
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 CAPTAIN EAMES CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721
Mailing Address - Country:US
Mailing Address - Phone:617-417-2623
Mailing Address - Fax:
Practice Address - Street 1:10 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:781-449-1143
Practice Address - Fax:781-449-5992
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8237103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist