Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501012527 | MI |
NPI | 1003089749 |
---|---|
Provider Name | Matthew Glenn |
First Address | Clarkston, MI 48346-4503 |
Second Address | Clarkston, MI 48346-4503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2008 |
Last Update Date | 16/10/2013 |