Provider Demographics
NPI:1679198485
Name:GLICKSMAN, MINDEL S (MA-CCC)
Entity Type:Individual
Prefix:
First Name:MINDEL
Middle Name:S
Last Name:GLICKSMAN
Suffix:
Gender:F
Credentials:MA-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GOULD ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5310
Mailing Address - Country:US
Mailing Address - Phone:973-330-2807
Mailing Address - Fax:
Practice Address - Street 1:12 GOULD ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5310
Practice Address - Country:US
Practice Address - Phone:973-330-2807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00686400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty