Provider Demographics
NPI:1699012609
Name:GLASS, LAURIE ANNE (PTA)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANNE
Last Name:GLASS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 HILLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3016
Mailing Address - Country:US
Mailing Address - Phone:201-670-4985
Mailing Address - Fax:
Practice Address - Street 1:42 HILLMAN AVE
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3016
Practice Address - Country:US
Practice Address - Phone:201-670-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4OQB00266800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant