Provider Demographics
NPI:1154332773
Name:GLADE, MICHAEL SCOTT (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:GLADE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7309 QUARTZITE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3541
Mailing Address - Country:US
Mailing Address - Phone:505-890-8767
Mailing Address - Fax:
Practice Address - Street 1:242 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2602
Practice Address - Country:US
Practice Address - Phone:505-876-6030
Practice Address - Fax:505-876-6151
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist