Provider Demographics
NPI:1346991213
Name:GLACKIN, MARYKATE (PTA)
Entity Type:Individual
Prefix:
First Name:MARYKATE
Middle Name:
Last Name:GLACKIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 LEFFERTS LN
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2331
Mailing Address - Country:US
Mailing Address - Phone:732-770-9628
Mailing Address - Fax:
Practice Address - Street 1:570 SOUTH AVE E STE C
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-3200
Practice Address - Country:US
Practice Address - Phone:908-325-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00365200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QB00365200OtherNEW JERSEY STATE BOARD OF PHYSICAL THERAPY