Provider Demographics
NPI:1871676478
Name:GLUCK, CHARLES W (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:W
Last Name:GLUCK
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 LANDING AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1732
Mailing Address - Country:US
Mailing Address - Phone:631-979-6450
Mailing Address - Fax:
Practice Address - Street 1:159 INDIAN HEAD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2205
Practice Address - Country:US
Practice Address - Phone:631-543-4500
Practice Address - Fax:631-543-5162
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0209001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN8B022Medicare ID - Type Unspecified