Provider Demographics
NPI:1285814657
Name:RICHARDSON, GLEN ADAM (ATC)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ADAM
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 LORETTO RD
Mailing Address - Street 2:SPRING VIEW REHABILITATION SERVICES
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1300
Mailing Address - Country:US
Mailing Address - Phone:270-692-5130
Mailing Address - Fax:
Practice Address - Street 1:320 LORETTO RD
Practice Address - Street 2:SPRING VIEW REHABILITATION SERVICES
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1300
Practice Address - Country:US
Practice Address - Phone:270-692-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT5012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer