Provider Demographics
NPI:1063043669
Name:KAISER, GLENNA LEANN (CMT)
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:LEANN
Last Name:KAISER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-1806
Mailing Address - Country:US
Mailing Address - Phone:812-660-2270
Mailing Address - Fax:
Practice Address - Street 1:202 S 4TH ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-1806
Practice Address - Country:US
Practice Address - Phone:812-660-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21003844225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist