Provider Demographics
NPI:1265872667
Name:GLENN, REBECCA (LMP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S PARKWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-9294
Mailing Address - Country:US
Mailing Address - Phone:360-687-1781
Mailing Address - Fax:
Practice Address - Street 1:113 S PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-9294
Practice Address - Country:US
Practice Address - Phone:360-687-1781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00021731172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist