Provider Demographics
NPI:1134363971
Name:DATRES, GLEN P (AUD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:P
Last Name:DATRES
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4109
Mailing Address - Country:US
Mailing Address - Phone:413-447-2752
Mailing Address - Fax:413-496-6836
Practice Address - Street 1:780 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-2148
Practice Address - Country:US
Practice Address - Phone:413-528-3606
Practice Address - Fax:413-528-3607
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000439231H00000X
MA802231H00000X
NY856231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist