Provider Demographics
NPI:1295083699
Name:PETERSON, GLENN (PTA)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 OLD ALICE RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8268
Mailing Address - Country:US
Mailing Address - Phone:615-714-8177
Mailing Address - Fax:
Practice Address - Street 1:871 OLD ALICE RD
Practice Address - Street 2:SUITE 600
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8268
Practice Address - Country:US
Practice Address - Phone:615-714-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2088488222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2088488OtherSTATE LICENSE NUMBER
TX2088488OtherSTATE LICENCE NUMBER