Provider Demographics
NPI:1194872721
Name:GLOYD, SAMUEL JEROME (MDIV)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JEROME
Last Name:GLOYD
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-2129
Mailing Address - Country:US
Mailing Address - Phone:617-527-5804
Mailing Address - Fax:
Practice Address - Street 1:268 NEWBURY ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2424
Practice Address - Country:US
Practice Address - Phone:617-247-4143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health