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General NPI Number Information
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NPI Number | 1164558318
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Entity Type | Individual
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Provider Name | MARY LEONORA GLENN PH.D.
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Gender | Female
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Dates
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Enumeration Date | 02/24/2007
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Last Update Date | 12/07/2025
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Provider Practice Location Address
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Address Line | 256 CONCORD AVE
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City | CAMBRIDGE
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State | MA
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Zip | 02138-1337
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Country | US
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Telephone | 617-864-4220
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Fax |
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Provider Business Mailing Address
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Address Line | 14 PARK LN
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City | JAMAICA PLAIN
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State | MA
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Zip | 02130-2906
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Country | US
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Telephone | 617-524-7290
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Fax | 617-524-7290
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0700X
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Taxonomy Name | Adult Development & Aging Psychologist
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License Number | 6462
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6462
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number | 6462
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License Number State | MA
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6462
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License Number State | MA
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