Provider Demographics
NPI:1821154469
Name:SOBERMAN, GLENN B (PHD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:SOBERMAN
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 1:52 S MANHEIM BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-2406
Mailing Address - Country:US
Mailing Address - Phone:845-255-2443
Mailing Address - Fax:845-853-1547
Practice Address - Street 1:52 S MANHEIM BLVD
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-2406
Practice Address - Country:US
Practice Address - Phone:845-255-2443
Practice Address - Fax:845-853-1547
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014273103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02206384Medicaid
NY02206384Medicaid
NYV18581Medicare PIN