Provider Demographics
NPI:1609013200
Name:BACHRACH, GLENN (PH D)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:BACHRACH
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 AVENUE J
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4445
Mailing Address - Country:US
Mailing Address - Phone:347-624-0637
Mailing Address - Fax:
Practice Address - Street 1:4305 AVENUE J
Practice Address - Street 2:SUITE 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4445
Practice Address - Country:US
Practice Address - Phone:347-624-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN/A252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency