Provider Demographics
NPI:1033413083
Name:TATE, GLENN F (LMP)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:F
Last Name:TATE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17620 80TH AVE NE
Mailing Address - Street 2:APT# 302
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-6602
Mailing Address - Country:US
Mailing Address - Phone:425-949-2617
Mailing Address - Fax:
Practice Address - Street 1:17620 80TH AVE NE
Practice Address - Street 2:APT# 302
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-6602
Practice Address - Country:US
Practice Address - Phone:425-949-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60172753225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist