Provider Demographics
NPI:1326561218
Name:GLASCOCK, EBONY (ATC, EMT)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:GLASCOCK
Suffix:
Gender:F
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W CHURCH ST APT E
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2959
Mailing Address - Country:US
Mailing Address - Phone:770-833-2908
Mailing Address - Fax:
Practice Address - Street 1:800 GALLOWAY DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70402-0001
Practice Address - Country:US
Practice Address - Phone:985-549-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3064502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer