Provider Demographics
NPI:1467484378
Name:GLAZA, CARRIE L (PT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:GLAZA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 W COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1001
Mailing Address - Country:US
Mailing Address - Phone:708-361-3600
Mailing Address - Fax:
Practice Address - Street 1:4710 W 95TH ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2546
Practice Address - Country:US
Practice Address - Phone:708-529-0348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL568150OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP NUMBER
IL1623066OtherBCBS PROVIDER NUMBER
IL367885100OtherUS DEPT OF LABOR
IL1623066OtherBCBS PROVIDER NUMBER
ILL99000Medicare PIN
IL202542Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL367885100OtherUS DEPT OF LABOR
IL567770Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER