Provider Demographics
NPI:1205131638
Name:WHEELER, GLEN SLAYTON (PT, LMT)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:SLAYTON
Last Name:WHEELER
Suffix:
Gender:M
Credentials:PT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2726 ELECTRIC RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3528
Mailing Address - Country:US
Mailing Address - Phone:540-989-8974
Mailing Address - Fax:540-989-4695
Practice Address - Street 1:2726 ELECTRIC RD STE 101
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3528
Practice Address - Country:US
Practice Address - Phone:540-989-8974
Practice Address - Fax:540-989-4695
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-15
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist