Provider Demographics
NPI:1255432696
Name:GLASSMAN, NATHAN DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DAVID
Last Name:GLASSMAN
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 1:2323 N LAKE DR
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4508
Mailing Address - Country:US
Mailing Address - Phone:414-585-6120
Mailing Address - Fax:
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:SUITE #270
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-444-9811
Practice Address - Fax:414-444-9822
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1653103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000144505Medicare ID - Type UnspecifiedCLINIC