Healthcare Provider Details

I. General information

NPI: 1710700190
Provider Name (Legal Business Name): GLENN A YELICH SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING BLOCKS LEARNING CENTER #19 ROBINSON ROAD
CLINTON NY
13323
US

IV. Provider business mailing address

BUILDING BLOCKS LEARNING CENTER #19 ROBINSON ROAD
CLINTON NY
13323
US

V. Phone/Fax

Practice location:
  • Phone: 315-853-6090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number314644901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: