Provider Demographics
NPI:1821416058
Name:ILACQUA, GLEN (MA)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:ILACQUA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WHITE CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-8009
Mailing Address - Country:US
Mailing Address - Phone:781-264-3449
Mailing Address - Fax:
Practice Address - Street 1:47 WHITE CLIFF DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-8009
Practice Address - Country:US
Practice Address - Phone:781-264-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health