Provider Demographics
NPI:1518261874
Name:GLENN S. FAGEN PHD INC
Entity Type:Organization
Organization Name:GLENN S. FAGEN PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:413-584-8339
Mailing Address - Street 1:100 KING ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3243
Mailing Address - Country:US
Mailing Address - Phone:413-584-8339
Mailing Address - Fax:413-584-8807
Practice Address - Street 1:100 KING ST
Practice Address - Street 2:SUITE 303
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3243
Practice Address - Country:US
Practice Address - Phone:413-584-8339
Practice Address - Fax:413-584-8339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6793261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0524484Medicaid
MAW05440OtherBLUE CROSS AND BLUE SHIELD
MAW05440OtherBLUE CROSS AND BLUE SHIELD