Provider Demographics
NPI:1619967148
Name:CAMPBELL, GLENN MARVIN (OTRIL PTA)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:MARVIN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:OTRIL PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7402 METZGER AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:ELMENDORF AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99506-2021
Mailing Address - Country:US
Mailing Address - Phone:907-333-8281
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:3RD MDG
Practice Address - City:ELMENDORF AFB
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-580-1700
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE000241L225200000X
PAOC002460L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist