Provider Demographics
NPI:1780181305
Name:GLACKIN PHYSIOTHERAPY, LLC
Entity Type:Organization
Organization Name:GLACKIN PHYSIOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GLACKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:908-328-3074
Mailing Address - Street 1:247 S ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2215
Mailing Address - Country:US
Mailing Address - Phone:908-328-3074
Mailing Address - Fax:
Practice Address - Street 1:9159 RED BRANCH RD STE F
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2041
Practice Address - Country:US
Practice Address - Phone:908-328-3074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25821261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1932565298Medicaid