Provider Demographics
NPI:1659756179
Name:GLENN, ELIZABETH REBECCA (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:REBECCA
Last Name:GLENN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:R
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1850 YOSEMITE AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4218
Mailing Address - Country:US
Mailing Address - Phone:805-636-9637
Mailing Address - Fax:
Practice Address - Street 1:2600 COMPASS RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8001
Practice Address - Country:US
Practice Address - Phone:877-787-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3656224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant