Provider Demographics
NPI:1679909519
Name:GLICK, SOMA OLISOA (LICAC, DOM)
Entity type:Individual
Prefix:MRS
First Name:SOMA
Middle Name:OLISOA
Last Name:GLICK
Suffix:
Gender:F
Credentials:LICAC, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 ORANGE PL
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0730
Mailing Address - Country:US
Mailing Address - Phone:303-931-6289
Mailing Address - Fax:
Practice Address - Street 1:6620 GUNPARK DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3339
Practice Address - Country:US
Practice Address - Phone:303-581-9955
Practice Address - Fax:303-581-9944
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO466171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist