1659422574 NPI number — MS. SOPHIE MARCELLE GLIKSON MAS

Table of content: MS. SOPHIE MARCELLE GLIKSON MAS (NPI 1659422574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659422574 NPI number — MS. SOPHIE MARCELLE GLIKSON MAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLIKSON
Provider First Name:
SOPHIE
Provider Middle Name:
MARCELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MAS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLIKSON CAHEN
Provider Other First Name:
SOPHIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1659422574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
142 WALSH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-874-0709
Provider Business Mailing Address Fax Number:
781-874-0224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
142 WALSH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-1245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-874-0709
Provider Business Practice Location Address Fax Number:
781-874-0224
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  3110 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3110 . This is a "LHHC LICENSE MENTAL HEALT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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