Provider Demographics
NPI:1710106992
Name:GLENN, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 GRACEFUL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2028
Mailing Address - Country:US
Mailing Address - Phone:501-413-9546
Mailing Address - Fax:501-325-1315
Practice Address - Street 1:1001 N TYLER ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1749
Practice Address - Country:US
Practice Address - Phone:501-413-9546
Practice Address - Fax:501-325-1315
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2081225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A035OtherBLUE CROSS BLUE SHIELD
AR161941721Medicaid