=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659339810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERALD A. GLUCK, PH.D,LMFT,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 07/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5401 N UNIVERSITY DR SUITE 104
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33067-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-227-0551
-----------------------------------------------------
Fax | 954-227-0592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5401 N UNIVERSITY DR SUITE 104
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33067-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-227-0551
-----------------------------------------------------
Fax | 954-227-0592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GERALD A GLUCK
-----------------------------------------------------
Credential | PH.D., LMFT
-----------------------------------------------------
Telephone | 954-227-0551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT1223
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------