Provider Demographics
NPI:1568856920
Name:LEVINE, GLENN ALAN (CRT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALAN
Last Name:LEVINE
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 GOLDEN WILLOW CT
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3210
Mailing Address - Country:US
Mailing Address - Phone:904-228-1259
Mailing Address - Fax:
Practice Address - Street 1:1427 GOLDEN WILLOW CT
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-3210
Practice Address - Country:US
Practice Address - Phone:904-228-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT4696227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTT4696OtherFLORIDA DEPT. OF HEALTH