Provider Demographics
NPI:1457845851
Name:GLASSBERG, GLENNE (RDN)
Entity Type:Individual
Prefix:
First Name:GLENNE
Middle Name:
Last Name:GLASSBERG
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:GILA
Other - Middle Name:
Other - Last Name:POLATOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:960 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1647
Mailing Address - Country:US
Mailing Address - Phone:570-878-3642
Mailing Address - Fax:
Practice Address - Street 1:1094 FULTON ST
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598
Practice Address - Country:US
Practice Address - Phone:570-878-3642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86066215133VN1004X, 133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY86066215Medicaid