Provider Demographics
NPI:1134456809
Name:THIE, GLENDA DORMAN (PT)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:DORMAN
Last Name:THIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2743
Mailing Address - Country:US
Mailing Address - Phone:208-882-3588
Mailing Address - Fax:
Practice Address - Street 1:872 TROY HIGHWAY
Practice Address - Street 2:SUITE 180
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2743
Practice Address - Country:US
Practice Address - Phone:208-882-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist