Provider Demographics
NPI:1669586103
Name:MACLEAN-TALBOT, GLENN (PT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MACLEAN-TALBOT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW INDIAN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-3037
Mailing Address - Country:US
Mailing Address - Phone:541-504-5363
Mailing Address - Fax:541-504-7677
Practice Address - Street 1:1020 SW INDIAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-3037
Practice Address - Country:US
Practice Address - Phone:541-504-5363
Practice Address - Fax:541-504-7677
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5749225100000X
ME3177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5749OtherPHYSICAL THERAPY LICENSE NUMBER