Provider Demographics
NPI:1740752146
Name:GLENN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
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 1:109 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-1703
Mailing Address - Country:US
Mailing Address - Phone:812-605-2889
Mailing Address - Fax:
Practice Address - Street 1:1701 LIBRARY BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1567
Practice Address - Country:US
Practice Address - Phone:317-881-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist