Provider Demographics
NPI:1821242819
Name:LAVALLEE, GLENN EDWARD (MSPT)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:EDWARD
Last Name:LAVALLEE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GRANDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2344
Mailing Address - Country:US
Mailing Address - Phone:860-355-5101
Mailing Address - Fax:
Practice Address - Street 1:2 GRANDVIEW LN
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2344
Practice Address - Country:US
Practice Address - Phone:860-355-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026269-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics