Provider Demographics
NPI:1457507881
Name:MCLEOD, GLEN DAVID (PT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:DAVID
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11977
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81612-9390
Mailing Address - Country:US
Mailing Address - Phone:970-319-8111
Mailing Address - Fax:
Practice Address - Street 1:1450 CRYSTAL LAKE RD
Practice Address - Street 2:ASPEN SPORTS MEDICINE INSTITUTE
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-2255
Practice Address - Country:US
Practice Address - Phone:970-925-8940
Practice Address - Fax:970-925-9543
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5783225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic