Provider Demographics
NPI:1902995954
Name:GLASS, PAMELA M (LICSW)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:M
Last Name:GLASS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BIRD ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-4358
Mailing Address - Country:US
Mailing Address - Phone:781-449-7940
Mailing Address - Fax:781-449-8045
Practice Address - Street 1:36 WESTON AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02170-1833
Practice Address - Country:US
Practice Address - Phone:617-786-0137
Practice Address - Fax:617-479-4798
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1056111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3700Medicare ID - Type Unspecified