Provider Demographics
NPI:1932134947
Name:FAGEN, GLENN SCOTT (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:SCOTT
Last Name:FAGEN
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 1:100 KING STREET
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060
Mailing Address - Country:US
Mailing Address - Phone:413-584-8339
Mailing Address - Fax:413-584-8807
Practice Address - Street 1:100 KING STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060
Practice Address - Country:US
Practice Address - Phone:413-584-8339
Practice Address - Fax:413-584-8807
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6793103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0524484Medicaid
MAW50024Medicare ID - Type Unspecified