1184742009 NPI number — JAY HOWARD GLICKMAN LPCC

Table of content: CYNTHIA MATCHA LPC (NPI 1972766533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184742009 NPI number — JAY HOWARD GLICKMAN LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLICKMAN
Provider First Name:
JAY
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184742009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 DE MOSS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LORDSBURG
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88045-2618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-542-8384
Provider Business Mailing Address Fax Number:
575-542-8367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W COLLEGE AVE
Provider Second Line Business Practice Location Address:
HMS SILVER CITY MENTAL HEALTH CENTER
Provider Business Practice Location Address City Name:
SILVER CITY
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-313-8222
Provider Business Practice Location Address Fax Number:
575-542-8367
Provider Enumeration Date:
03/27/2007

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: 101Y00000X , with the licence number:  0103521 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24785806 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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