Provider Demographics
NPI:1619198470
Name:SAMPSON, GLENN CRAIG (PT)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:CRAIG
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 SE HERRON AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-225-8908
Mailing Address - Fax:
Practice Address - Street 1:702 JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957
Practice Address - Country:US
Practice Address - Phone:772-225-8908
Practice Address - Fax:772-225-0843
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist