Provider Demographics
NPI:1447448600
Name:WILLIAMSON, GLEN RICHARD (LCSW)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:RICHARD
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W 72ND ST
Mailing Address - Street 2:16C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3210
Mailing Address - Country:US
Mailing Address - Phone:212-787-2527
Mailing Address - Fax:
Practice Address - Street 1:309 W 74TH ST
Practice Address - Street 2:BASEMENT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-1604
Practice Address - Country:US
Practice Address - Phone:212-787-2527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPO62364-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNV3851Medicare PIN