Provider Demographics
NPI:1376908137
Name:GLICK, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:GLICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TUFTS RD
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-7426
Mailing Address - Country:US
Mailing Address - Phone:617-590-4108
Mailing Address - Fax:
Practice Address - Street 1:124 WATERTOWN ST
Practice Address - Street 2:SUITE 2-E
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2576
Practice Address - Country:US
Practice Address - Phone:617-272-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator