Provider Demographics
NPI:1740425818
Name:GLICKSMAN, STEPHEN IAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:IAN
Last Name:GLICKSMAN
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 1:1169 SUSSEX RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2770
Mailing Address - Country:US
Mailing Address - Phone:201-692-1866
Mailing Address - Fax:718-853-0818
Practice Address - Street 1:1556 38TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-4408
Practice Address - Country:US
Practice Address - Phone:718-670-3290
Practice Address - Fax:718-853-0818
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013863103T00000X
NJ4598103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist