Provider Demographics
NPI:1821372921
Name:GLICK, BONNIE G
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:G
Last Name:GLICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 E NOXON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-4302
Mailing Address - Country:US
Mailing Address - Phone:845-223-8030
Mailing Address - Fax:
Practice Address - Street 1:1659 E NOXON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-4302
Practice Address - Country:US
Practice Address - Phone:845-223-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002068-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist