Provider Demographics
NPI:1659489862
Name:GLICKMAN, NEIL (PHD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:GLICKMAN
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 1:3 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-3211
Mailing Address - Country:US
Mailing Address - Phone:508-647-1794
Mailing Address - Fax:508-628-7322
Practice Address - Street 1:3 VERNON RD
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-3211
Practice Address - Country:US
Practice Address - Phone:508-647-1794
Practice Address - Fax:508-628-7322
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05364Medicare PIN