Provider Demographics
NPI:1578655122
Name:CANDELETTI, GLENN R (PHD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:CANDELETTI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 LACEY RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1533
Mailing Address - Country:US
Mailing Address - Phone:609-693-7903
Mailing Address - Fax:
Practice Address - Street 1:535 LACEY RD
Practice Address - Street 2:SUITE 6
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1533
Practice Address - Country:US
Practice Address - Phone:609-693-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00202900103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ33090Medicare ID - Type Unspecified