Provider Demographics
NPI:1447845490
Name:GLYNN, COLLEEN ELIZABETH
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:GLYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1838
Mailing Address - Country:US
Mailing Address - Phone:978-810-5858
Mailing Address - Fax:
Practice Address - Street 1:48 SALEM ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1838
Practice Address - Country:US
Practice Address - Phone:978-810-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100203282189Medicaid