Provider Demographics
NPI:1972860187
Name:DEGERE, GLENN EMERY (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:EMERY
Last Name:DEGERE
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-2207
Mailing Address - Country:US
Mailing Address - Phone:781-698-8321
Mailing Address - Fax:
Practice Address - Street 1:90 VANDENBERG DR BLDG 1900
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-225-6789
Practice Address - Fax:781-225-2568
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1154391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical