Provider Demographics
NPI:1649824012
Name:HURST, GLENDORA L (DPT)
Entity type:Individual
Prefix:
First Name:GLENDORA
Middle Name:L
Last Name:HURST
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 TREES OF AVALON PKWY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 FLAT SHOALS RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6638
Practice Address - Country:US
Practice Address - Phone:770-785-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist