Provider Demographics
NPI:1235357443
Name:GLENN, CONNIE EILENE (COTA)
Entity Type:Individual
Prefix:MR
First Name:CONNIE
Middle Name:EILENE
Last Name:GLENN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 GREEN ACRES DR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:TX
Mailing Address - Zip Code:75152-9613
Mailing Address - Country:US
Mailing Address - Phone:972-921-1208
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:214-467-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209643224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant