Basic Information
| Provider Information | |||||||||
| NPI: | 1134363971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DATRES | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472752 | ||||||||
| FaxNumber: | 4134966836 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012302148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135283606 | ||||||||
| FaxNumber: | 4135283607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 000439 | CT | Y | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 802 | MA | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 856 | NY | N | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.