Provider Demographics
NPI:1083766026
Name:LASATER, GLYN ELIZABETH (RPT)
Entity Type:Individual
Prefix:MRS
First Name:GLYN
Middle Name:ELIZABETH
Last Name:LASATER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MS
Other - First Name:GLYN
Other - Middle Name:ELIZABETH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:131 BOSTON POST RD.
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333
Mailing Address - Country:US
Mailing Address - Phone:860-739-4497
Mailing Address - Fax:860-739-7256
Practice Address - Street 1:131 BOSTON POST RD.
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333
Practice Address - Country:US
Practice Address - Phone:860-739-4497
Practice Address - Fax:860-739-7256
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist