Provider Demographics
NPI:1568413847
Name:GLOVER, RYAN DOUGLAS (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DOUGLAS
Last Name:GLOVER
Suffix:
Gender:M
Credentials:OTR/L, CHT
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 2485
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-0660
Mailing Address - Country:US
Mailing Address - Phone:503-674-7860
Mailing Address - Fax:503-674-7642
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:STE 200
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-491-1666
Practice Address - Fax:503-491-1667
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1023386225X00000X
OR1041100414225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR134504Medicare PIN
OR5725030001Medicare NSC
OR5725030002Medicare NSC
ORR134505Medicare PIN