Provider Demographics
NPI:1861508269
Name:GLASS, KENNETH LAWRENCE (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LAWRENCE
Last Name:GLASS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 US HWY 74A
Mailing Address - Street 2:SUITE 341
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043
Mailing Address - Country:US
Mailing Address - Phone:828-247-1588
Mailing Address - Fax:828-247-1692
Practice Address - Street 1:2270 US HWY 74A
Practice Address - Street 2:SUITE 341
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043
Practice Address - Country:US
Practice Address - Phone:828-247-1588
Practice Address - Fax:828-247-1692
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4131225100000X
SC3312225100000X
CA25431225100000X
OR3786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist