Provider Demographics
NPI:1720539885
Name:GLAESER, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GLAESER
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 1:5558 NOVAK AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2132
Mailing Address - Country:US
Mailing Address - Phone:651-468-5584
Mailing Address - Fax:
Practice Address - Street 1:5600 NORWICH PKWY
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6482
Practice Address - Country:US
Practice Address - Phone:651-430-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9979225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist