Provider Demographics
NPI:1437413077
Name:ATAKULU, GLENDA
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:ATAKULU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-3128
Mailing Address - Country:US
Mailing Address - Phone:513-545-6011
Mailing Address - Fax:
Practice Address - Street 1:2350 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-3128
Practice Address - Country:US
Practice Address - Phone:513-545-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2019-01-15
Deactivation Date:2013-04-03
Deactivation Code:
Reactivation Date:2019-01-15
Provider Licenses
StateLicense IDTaxonomies
MDA2476225200000X
OHPTA04900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant