Provider Demographics
NPI:1164609889
Name:OTEY, GLENN ROBERT
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ROBERT
Last Name:OTEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5473
Mailing Address - Country:US
Mailing Address - Phone:618-463-9490
Mailing Address - Fax:618-463-9491
Practice Address - Street 1:3119 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5473
Practice Address - Country:US
Practice Address - Phone:618-463-9490
Practice Address - Fax:618-463-9491
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2946237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist