Provider Demographics
NPI:1659362440
Name:GLICKMAN, ELAINE SUE (RNCS)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:SUE
Last Name:GLICKMAN
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 GOVERNORS AVE
Mailing Address - Street 2:LAWRENCE MEMORIAL HOSPITAL PSYCH
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1643
Mailing Address - Country:US
Mailing Address - Phone:781-306-6150
Mailing Address - Fax:781-306-6147
Practice Address - Street 1:170 GOVERNORS AVE
Practice Address - Street 2:LAWRENCE MEMORIAL HOSPITAL PSYCH
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1643
Practice Address - Country:US
Practice Address - Phone:781-306-6150
Practice Address - Fax:781-306-6147
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107028163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1200992Medicaid
S52963Medicare UPIN
MA1200992Medicaid