Provider Demographics
NPI:1154694792
Name:GLIDDEN, BROM (MA)
Entity type:Individual
Prefix:
First Name:BROM
Middle Name:
Last Name:GLIDDEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 N CENTER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-7148
Mailing Address - Country:US
Mailing Address - Phone:208-597-0994
Mailing Address - Fax:
Practice Address - Street 1:534 N CENTER VALLEY RD
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-7148
Practice Address - Country:US
Practice Address - Phone:208-597-0994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCP-4881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health