Provider Demographics
NPI:1134202989
Name:GLAZER, MICHAEL WARREN (PHD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WARREN
Last Name:GLAZER
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 1:3594 EAST TREMONT AVENUE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-2032
Mailing Address - Country:US
Mailing Address - Phone:718-792-4178
Mailing Address - Fax:718-792-2496
Practice Address - Street 1:3594 EAST TREMONT AVENUE
Practice Address - Street 2:SUITE 210
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-2032
Practice Address - Country:US
Practice Address - Phone:718-792-4178
Practice Address - Fax:718-792-2496
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004412103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
147475OtherVALUE OPTIONS
00441268OtherHIP
V1849OtherEMPIRE
VF037OtherEMPIRE
P821454OtherOXFORD
1053460OtherBEACON
A2367OtherLOCAL 1199
NYV181491Medicare ID - Type Unspecified