Provider Demographics
NPI:1770662496
Name:GLICK, DOUGLAS ADAM (LMSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ADAM
Last Name:GLICK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W FRONT ST STE 405
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2279
Mailing Address - Country:US
Mailing Address - Phone:231-518-9258
Mailing Address - Fax:231-216-2793
Practice Address - Street 1:310 W FRONT ST STE 405
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2279
Practice Address - Country:US
Practice Address - Phone:231-518-9258
Practice Address - Fax:231-216-2793
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040063681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05700OtherGROUP PTAN
VA010326435Medicaid