Healthcare Provider Details

I. General information

NPI: 1447497854
Provider Name (Legal Business Name): THEODORE E GLACKMAN M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BROAD ST 17TH FLOOR
PHILADELPHIA PA
19110-1023
US

IV. Provider business mailing address

517 E SPRING AVE
ARDMORE PA
19003-3123
US

V. Phone/Fax

Practice location:
  • Phone: 267-474-9417
  • Fax:
Mailing address:
  • Phone: 215-701-1560
  • Fax: 215-701-1572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS004176L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: