Provider Demographics
NPI:1316915093
Name:GLAZER, MICHAEL ALAN (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:GLAZER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PASEO CAMARILLO
Mailing Address - Street 2:STE 245
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6085
Mailing Address - Country:US
Mailing Address - Phone:805-482-7866
Mailing Address - Fax:805-388-3039
Practice Address - Street 1:1200 PASEO CAMARILLO
Practice Address - Street 2:STE 245
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6085
Practice Address - Country:US
Practice Address - Phone:805-482-7866
Practice Address - Fax:805-388-3039
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6437103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY6437OtherSTATE LICENSE
CAPSY6437OtherSTATE LICENSE
CAR62004Medicare ID - Type Unspecified