Provider Demographics
NPI:1447977624
Name:GLICK, CAMERON MICHAEL
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:MICHAEL
Last Name:GLICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 AMERICAN LEGION HWY
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3908
Mailing Address - Country:US
Mailing Address - Phone:888-922-2843
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:780 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3908
Practice Address - Country:US
Practice Address - Phone:617-267-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2024-10-16
Deactivation Date:2024-08-30
Deactivation Code:
Reactivation Date:2024-09-10
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician