Provider Demographics
NPI:1205103181
Name:GLASS, KRISTEN RUBY (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:RUBY
Last Name:GLASS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 NE STALLINGS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1239
Mailing Address - Country:US
Mailing Address - Phone:936-560-1618
Mailing Address - Fax:936-560-3554
Practice Address - Street 1:4848 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1239
Practice Address - Country:US
Practice Address - Phone:936-560-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1207617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist