Healthcare Provider Details

I. General information

NPI: 1164558318
Provider Name (Legal Business Name): MARY LEONORA GLENN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 12/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 CONCORD AVE
CAMBRIDGE MA
02138-1337
US

IV. Provider business mailing address

14 PARK LN
JAMAICA PLAIN MA
02130-2906
US

V. Phone/Fax

Practice location:
  • Phone: 617-864-4220
  • Fax:
Mailing address:
  • Phone: 617-524-7290
  • Fax: 617-524-7290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number6462
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6462
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number6462
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6462
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: