Provider Demographics
NPI:1629423843
Name:GLICKLICH, ROSALYN
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:
Last Name:GLICKLICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 JEFFERSON AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2392
Mailing Address - Country:US
Mailing Address - Phone:914-255-4624
Mailing Address - Fax:
Practice Address - Street 1:75-59 263RD ST.
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004
Practice Address - Country:US
Practice Address - Phone:914-255-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program