Provider Demographics
NPI:1013741768
Name:GLENN, BRAYDEN R (DPT)
Entity type:Individual
Prefix:
First Name:BRAYDEN
Middle Name:R
Last Name:GLENN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 PLEASANT VIEW RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1257
Mailing Address - Country:US
Mailing Address - Phone:435-237-9068
Mailing Address - Fax:
Practice Address - Street 1:436 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-3009
Practice Address - Country:US
Practice Address - Phone:304-465-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist