Provider Demographics
NPI:1336111400
Name:NEAL, GLEN EDWARD (MPT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:NEAL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1087 13TH ST SE
Mailing Address - Street 2:CHILDREN'S NEUROTHERAPY SERVICES
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4165
Mailing Address - Country:US
Mailing Address - Phone:828-267-1688
Mailing Address - Fax:828-267-1690
Practice Address - Street 1:1087 13TH ST SE
Practice Address - Street 2:CHILDREN'S NEUROTHERAPY SERVICES
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4165
Practice Address - Country:US
Practice Address - Phone:828-267-1688
Practice Address - Fax:828-267-1690
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83742251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
9157627OtherPHCS
NCA3902OtherMEDCOST
11314691OtherCAQH
NC1274JOtherBCBS
NC7210860Medicaid