Healthcare Provider Details

I. General information

NPI: 1659362440
Provider Name (Legal Business Name): ELAINE SUE GLICKMAN RNCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 GOVERNORS AVE LAWRENCE MEMORIAL HOSPITAL PSYCH
MEDFORD MA
02155-1643
US

IV. Provider business mailing address

170 GOVERNORS AVE LAWRENCE MEMORIAL HOSPITAL PSYCH
MEDFORD MA
02155-1643
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-6150
  • Fax: 781-306-6147
Mailing address:
  • Phone: 781-306-6150
  • Fax: 781-306-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number107028
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: