Provider Demographics
NPI:1245062801
Name:GLASS, KENLIE KAY
Entity type:Individual
Prefix:
First Name:KENLIE
Middle Name:KAY
Last Name:GLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932184
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2431 S LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1519
Practice Address - Country:US
Practice Address - Phone:806-771-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1396397225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist