Provider Demographics
NPI:1063677151
Name:GLENN, HOLLY MARI (PTA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARI
Last Name:GLENN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18187 150TH ST
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52553-8139
Mailing Address - Country:US
Mailing Address - Phone:641-777-6141
Mailing Address - Fax:
Practice Address - Street 1:18187 150TH ST
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:IA
Practice Address - Zip Code:52553-8139
Practice Address - Country:US
Practice Address - Phone:641-777-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01129225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant