Provider Demographics
NPI:1205695830
Name:GLUCKSMAN, SCOTT EVAN (LATC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:EVAN
Last Name:GLUCKSMAN
Suffix:
Gender:M
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CLUB RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-2120
Mailing Address - Country:US
Mailing Address - Phone:203-912-5206
Mailing Address - Fax:
Practice Address - Street 1:125 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1295
Practice Address - Country:US
Practice Address - Phone:203-912-5206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54.0005772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer