Provider Demographics
NPI:1780121012
Name:FOREMAN, GLEN JUNIOR (PT, DPT, LAT, ATC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:JUNIOR
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3618
Mailing Address - Country:US
Mailing Address - Phone:203-988-5560
Mailing Address - Fax:
Practice Address - Street 1:60 MARKET ST STE 130
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4282
Practice Address - Country:US
Practice Address - Phone:860-703-8505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2023-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14.0137942251X0800X
FLF655290951260390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic