Provider Demographics
NPI:1851541536
Name:GLASS, KATHLEEN MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:GLASS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WETZEL RD
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-2021
Mailing Address - Country:US
Mailing Address - Phone:610-845-3417
Mailing Address - Fax:
Practice Address - Street 1:2125 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:LAURELDALE
Practice Address - State:PA
Practice Address - Zip Code:19605-2259
Practice Address - Country:US
Practice Address - Phone:610-921-9292
Practice Address - Fax:610-939-9256
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000352L314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA225200000XOtherPHYSICAL THERAPIST ASSISITANT