Provider Demographics
NPI:1790961928
Name:GLENN HOGBERG, HEATHER D (LMP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:D
Last Name:GLENN HOGBERG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N. OLYMPIC AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223
Mailing Address - Country:US
Mailing Address - Phone:360-435-9200
Mailing Address - Fax:360-435-5047
Practice Address - Street 1:415 N. OLYMPIC AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-435-9200
Practice Address - Fax:360-435-5047
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022972225700000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG115112900Medicare PIN