MEDICARE: PATRICIA M GLICKMAN MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC 49152	CA

General Provider Information

NPI Number	:	1790074839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA M GLICKMAN MFT

Provider Business Mailing Address
First Line	:	625 SUITE B 14TH ST
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-5503
Country	:	US
Telephone Number	:	805-610-8729
Fax Number	:	805-876-5412

Provider Business Practice Location Address
First Line	:	625 14TH ST STE B
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-7213
Country	:	US
Telephone Number	:	805-610-8729
Fax Number	:	805-876-5412

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	12/12/2013

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