Provider Demographics
NPI:1043751704
Name:GLENNON, TRISTIN
Entity Type:Individual
Prefix:
First Name:TRISTIN
Middle Name:
Last Name:GLENNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SE 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-8234
Mailing Address - Country:US
Mailing Address - Phone:425-457-0832
Mailing Address - Fax:
Practice Address - Street 1:401 SE 148TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8234
Practice Address - Country:US
Practice Address - Phone:425-457-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR346029225X00000X
WAOT 60567292225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist