Provider Demographics
NPI:1114160363
Name:GLICK-RIDLEY, SANDRA (MSPT)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:GLICK-RIDLEY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W FINE AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3016
Mailing Address - Country:US
Mailing Address - Phone:928-773-9695
Mailing Address - Fax:928-773-0208
Practice Address - Street 1:120 W FINE AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3016
Practice Address - Country:US
Practice Address - Phone:928-773-9695
Practice Address - Fax:928-773-0208
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist