Provider Demographics
NPI:1447497854
Name:GLACKMAN, THEODORE E (MED)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:E
Last Name:GLACKMAN
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-3123
Mailing Address - Country:US
Mailing Address - Phone:215-701-1560
Mailing Address - Fax:215-701-1572
Practice Address - Street 1:100 S BROAD ST
Practice Address - Street 2:17TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110-1023
Practice Address - Country:US
Practice Address - Phone:267-474-9417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004176L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist