Provider Demographics
NPI:1639182256
Name:TREZZA, GLENN R (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:TREZZA
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 1:1 S MARKET ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-6145
Mailing Address - Country:US
Mailing Address - Phone:617-460-4262
Mailing Address - Fax:
Practice Address - Street 1:1 S MARKET ST STE 4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-6145
Practice Address - Country:US
Practice Address - Phone:617-460-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6647103TC0700X, 261QV0200X
NY011533103TC0700X, 261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW5077601Medicare UPIN
MATRW50776Medicare ID - Type UnspecifiedPSYCHOLOGY PROVIDER