Provider Demographics
NPI:1992180640
Name:CUTSHALL, GLEN (PT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:CUTSHALL
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 1:2100 MAIN ST STE 250
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2495
Mailing Address - Country:US
Mailing Address - Phone:714-374-0233
Mailing Address - Fax:714-374-0244
Practice Address - Street 1:2100 MAIN ST STE 250
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648
Practice Address - Country:US
Practice Address - Phone:714-374-0233
Practice Address - Fax:714-374-0244
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist