Provider Demographics
NPI:1003397639
Name:BORNMAN, GLENNA BETH (OTR)
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:BETH
Last Name:BORNMAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 CAMP DAVID ST
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-1922
Mailing Address - Country:US
Mailing Address - Phone:972-302-1491
Mailing Address - Fax:
Practice Address - Street 1:3617 O HARE DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4539
Practice Address - Country:US
Practice Address - Phone:972-284-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106441OtherTEXAS STATE BOARD OF PHYSICAL THERAPY AND OCCUPATIONAL THERAPY EXAMINERS