Provider Demographics
NPI:1730259391
Name:GLICK, MADELEINE (MS, RD, CDN)
Entity type:Individual
Prefix:MS
First Name:MADELEINE
Middle Name:
Last Name:GLICK
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-9777
Mailing Address - Country:US
Mailing Address - Phone:518-965-2074
Mailing Address - Fax:
Practice Address - Street 1:71 LOOMIS RD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NY
Practice Address - Zip Code:12037-9777
Practice Address - Country:US
Practice Address - Phone:518-965-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000515-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered