Provider Demographics
NPI:1003089749
Name:GLENN, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5896 DIXIE HWY STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4503
Mailing Address - Country:US
Mailing Address - Phone:248-461-6674
Mailing Address - Fax:248-461-6594
Practice Address - Street 1:5896 DIXIE HWY STE B
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4503
Practice Address - Country:US
Practice Address - Phone:248-461-6674
Practice Address - Fax:248-461-6594
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist