=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972987527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLYNN ROUX SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2015
-----------------------------------------------------
Last Update Date | 07/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 N MAIN ST
-----------------------------------------------------
City | SHARON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02067-1172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-875-5719
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 93
-----------------------------------------------------
City | SHARON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02067-0093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. MARY DEE GLYNN ROUX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-875-5719
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 9942
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------