Basic Information
| Provider Information | |||||||||
| NPI: | 1912135666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROSPERE | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 PIERCE STREET | ||||||||
| Address2: | |||||||||
| City: | HYDE PARK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173649464 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021181951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174252000 | ||||||||
| FaxNumber: | 6174248725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 07/06/2009 | ||||||||
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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 | 101YM0800X | 6911 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.