Provider Demographics
NPI:1912135666
Name:PROSPERE, GLEN T
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:T
Last Name:PROSPERE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 PIERCE STREET
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136
Mailing Address - Country:US
Mailing Address - Phone:617-364-9464
Mailing Address - Fax:
Practice Address - Street 1:1601 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1951
Practice Address - Country:US
Practice Address - Phone:617-425-2000
Practice Address - Fax:617-424-8725
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6911101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health