Provider Demographics
NPI:1326032392
Name:RICHARDSON, GLENN L (PT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:950 HIGHWAY 584
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-4328
Mailing Address - Country:US
Mailing Address - Phone:318-728-8879
Mailing Address - Fax:318-728-8879
Practice Address - Street 1:160 CHRISTIAN DR
Practice Address - Street 2:BOX 834
Practice Address - City:RAYVILLE
Practice Address - State:LA
Practice Address - Zip Code:71269-3645
Practice Address - Country:US
Practice Address - Phone:318-728-4088
Practice Address - Fax:318-728-4124
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 03589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1106135Medicaid
LA1106135Medicaid