Provider Demographics
NPI:1629139753
Name:HEISS, GLEN EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:EDWARD
Last Name:HEISS
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 1:171 MADISON AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5110
Mailing Address - Country:US
Mailing Address - Phone:212-243-2228
Mailing Address - Fax:
Practice Address - Street 1:171 MADISON AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5110
Practice Address - Country:US
Practice Address - Phone:212-243-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068-014713103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical