Provider Demographics
NPI:1962840439
Name:MCCLEISTER, GLENN (LMT, MMT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MCCLEISTER
Suffix:
Gender:M
Credentials:LMT, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4471 ELK POINT CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6206
Mailing Address - Country:US
Mailing Address - Phone:702-371-3702
Mailing Address - Fax:702-247-9744
Practice Address - Street 1:2595 S CIMARRON RD
Practice Address - Street 2:STE 206
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7613
Practice Address - Country:US
Practice Address - Phone:702-371-3702
Practice Address - Fax:702-247-9744
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.1007225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist