Healthcare Provider Details

I. General information

NPI: 1710001995
Provider Name (Legal Business Name): HOWARD NORMAN GLICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 MOODY CT SUITE 101
THOUSAND OAKS CA
91360-6067
US

IV. Provider business mailing address

5225 WHITE OAK AVE UNIT 7
ENCINO CA
91316-2457
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-3500
  • Fax:
Mailing address:
  • Phone: 818-996-5153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG16848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: