Provider Demographics
NPI:1033221551
Name:GLATTKE, THEODORE ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:ALAN
Last Name:GLATTKE
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:PO BOX 1298
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-1298
Mailing Address - Country:US
Mailing Address - Phone:925-284-5300
Mailing Address - Fax:925-284-5381
Practice Address - Street 1:3717 MT DIABLO BLVD
Practice Address - Street 2:SUITE100
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3588
Practice Address - Country:US
Practice Address - Phone:925-284-5300
Practice Address - Fax:925-284-5381
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17431ZMedicare ID - Type Unspecified