Provider Demographics
NPI:1780836700
Name:KERSHAW, GLENN EUGENE JR (PTA)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EUGENE
Last Name:KERSHAW
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9002 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6302
Mailing Address - Country:US
Mailing Address - Phone:440-266-1901
Mailing Address - Fax:440-266-1902
Practice Address - Street 1:9002 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6302
Practice Address - Country:US
Practice Address - Phone:440-266-1901
Practice Address - Fax:440-266-1902
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03121225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant