Provider Demographics
NPI:1972511863
Name:FODRA, GLENDALYN E (PT)
Entity Type:Individual
Prefix:MRS
First Name:GLENDALYN
Middle Name:E
Last Name:FODRA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WATAUGA CT
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-5340
Mailing Address - Country:US
Mailing Address - Phone:615-791-8793
Mailing Address - Fax:
Practice Address - Street 1:200 STRAHL ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-3556
Practice Address - Country:US
Practice Address - Phone:615-791-1103
Practice Address - Fax:615-791-7541
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist