Provider Demographics
NPI:1528771409
Name:WERNICK, GLEN DAVID
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:DAVID
Last Name:WERNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 NELSON AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-1735
Mailing Address - Country:US
Mailing Address - Phone:332-257-8821
Mailing Address - Fax:
Practice Address - Street 1:1422 NELSON AVE APT 2F
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-1735
Practice Address - Country:US
Practice Address - Phone:332-257-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002981-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health