Provider Demographics
NPI:1568053247
Name:GLICKMAN, RAPHAEL DAVID (LMSW)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:DAVID
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 DEPTFORD DR
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1659
Mailing Address - Country:US
Mailing Address - Phone:216-403-2808
Mailing Address - Fax:
Practice Address - Street 1:29125 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4622
Practice Address - Country:US
Practice Address - Phone:216-292-3999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.21016901041C0700X
OHS.2207842104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical