Provider Demographics
NPI:1164826863
Name:GLEOCKLER, BECKY
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:GLEOCKLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CIVIC AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-4599
Mailing Address - Country:US
Mailing Address - Phone:410-749-9292
Mailing Address - Fax:
Practice Address - Street 1:200 CIVIC AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-4599
Practice Address - Country:US
Practice Address - Phone:410-749-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3635225200000X
DEJ2-0000778225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant