Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist |
NPI | 1003468802 |
---|---|
Provider Name | Michele Glaze |
First Address | Thibodaux, LA 70301-6235 |
Second Address | Thibodaux, LA 70301-6235 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2019 |
Last Update Date | 11/07/2019 |