Provider Demographics
NPI:1801998703
Name:GLICK, MICHAEL (EDD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GLICK
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 LEMMON AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3760
Mailing Address - Country:US
Mailing Address - Phone:214-521-0451
Mailing Address - Fax:
Practice Address - Street 1:3906 LEMMON AVE STE 204
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-3760
Practice Address - Country:US
Practice Address - Phone:214-521-0451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096785301Medicaid
TX86070AOtherBCBS
TX8F20769Medicare PIN
TX86070AOtherBCBS