Provider Demographics
NPI:1548823644
Name:SMULYAN, GLENN MARLA (ATR-BC, LCAT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:MARLA
Last Name:SMULYAN
Suffix:
Gender:F
Credentials:ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 DORCHESTER RD APT 4C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5336
Mailing Address - Country:US
Mailing Address - Phone:917-399-0310
Mailing Address - Fax:
Practice Address - Street 1:184 BERKELEY PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3802
Practice Address - Country:US
Practice Address - Phone:917-727-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002049221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty