Provider Demographics
NPI:1700259405
Name:GLEZEN, ALISSA LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:LYNN
Last Name:GLEZEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:LYNN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:354 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18421-1418
Mailing Address - Country:US
Mailing Address - Phone:570-785-2018
Mailing Address - Fax:570-785-3575
Practice Address - Street 1:354 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:PA
Practice Address - Zip Code:18421-1418
Practice Address - Country:US
Practice Address - Phone:570-785-2018
Practice Address - Fax:570-785-3575
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013432225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103053753Medicaid
003328901OtherHIGHMARK
PA453116RHKMedicare PIN