Provider Demographics
NPI:1255485652
Name:BLY, GLENDA CLEMMER (LMT, RMT)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:CLEMMER
Last Name:BLY
Suffix:
Gender:F
Credentials:LMT, RMT
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:
Other - Last Name:BLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 784
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:TX
Mailing Address - Zip Code:79325-0784
Mailing Address - Country:US
Mailing Address - Phone:806-481-8181
Mailing Address - Fax:
Practice Address - Street 1:2905 N PRINCE ST
Practice Address - Street 2:SUITE C
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3843
Practice Address - Country:US
Practice Address - Phone:505-763-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3498225700000X
TXMT022683225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00RE56OtherBLUE CROSS & BLUE SHIELD