Provider Demographics
NPI:1477041580
Name:GLENN, IMANI NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:NICOLE
Last Name:GLENN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20219 HARLAN AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2549
Mailing Address - Country:US
Mailing Address - Phone:310-597-5846
Mailing Address - Fax:
Practice Address - Street 1:1575 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2675
Practice Address - Country:US
Practice Address - Phone:626-768-7764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner