Provider Demographics
NPI:1558440727
Name:GUCOR-VERGARA, GLENDA (RPT)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:GUCOR-VERGARA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22344 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3053
Mailing Address - Country:US
Mailing Address - Phone:810-814-0062
Mailing Address - Fax:586-598-4951
Practice Address - Street 1:22344 WOODLAKE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-3053
Practice Address - Country:US
Practice Address - Phone:810-814-0062
Practice Address - Fax:586-598-4951
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist