Provider Demographics
NPI:1760722136
Name:GLASSBERG, KEVIN A (OTR/L)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:GLASSBERG
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2547
Mailing Address - Country:US
Mailing Address - Phone:914-607-5730
Mailing Address - Fax:
Practice Address - Street 1:3030 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2574
Practice Address - Country:US
Practice Address - Phone:914-682-6435
Practice Address - Fax:914-681-3115
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5263225X00000X
NY023429225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
CT1760722136Medicaid