Basic Information
| Provider Information | |||||||||
| NPI: | 1174638480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLICK | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 HATCH DR | ||||||||
| Address2: | PO BOX 1018 | ||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047362161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074986431 | ||||||||
| FaxNumber: | 2074923181 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 MILL ST | ||||||||
| Address2: | |||||||||
| City: | HOULTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047301877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075326523 | ||||||||
| FaxNumber: | 2075321877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 351 | ME | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.