Provider Demographics
NPI:1659422574
Name:GLIKSON, SOPHIE MARCELLE (MAS)
Entity Type:Individual
Prefix:MS
First Name:SOPHIE
Middle Name:MARCELLE
Last Name:GLIKSON
Suffix:
Gender:F
Credentials:MAS
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:
Other - Last Name:GLIKSON CAHEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:142 WALSH STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1245
Mailing Address - Country:US
Mailing Address - Phone:781-874-0709
Mailing Address - Fax:781-874-0224
Practice Address - Street 1:142 WALSH STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1245
Practice Address - Country:US
Practice Address - Phone:781-874-0709
Practice Address - Fax:781-874-0224
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3110101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3110OtherLHHC LICENSE MENTAL HEALT