Provider Demographics
NPI:1962446864
Name:ROWELL, GLEN W (PT MA OCS)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:ROWELL
Suffix:
Gender:M
Credentials:PT MA OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596
Mailing Address - Country:US
Mailing Address - Phone:516-739-5503
Mailing Address - Fax:516-739-5565
Practice Address - Street 1:397 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596
Practice Address - Country:US
Practice Address - Phone:516-739-5503
Practice Address - Fax:516-739-5565
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ36163Medicare PIN
NY04760Medicare ID - Type Unspecified