Provider Demographics
NPI:1922877265
Name:GLAZE, KATIE JAYNE (MPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JAYNE
Last Name:GLAZE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 VERA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3016
Mailing Address - Country:US
Mailing Address - Phone:850-974-0632
Mailing Address - Fax:
Practice Address - Street 1:520 VERA CRUZ DR
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3016
Practice Address - Country:US
Practice Address - Phone:850-974-0632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist