Provider Demographics
NPI:1780299958
Name:GLAZIER-KERSAVAGE, CARLY JO (OTD)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:JO
Last Name:GLAZIER-KERSAVAGE
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JO
Other - Last Name:GLAZIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4225 E MCDOWELL RD APT 2093
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7472
Mailing Address - Country:US
Mailing Address - Phone:949-584-1626
Mailing Address - Fax:
Practice Address - Street 1:4225 E MCDOWELL RD APT 2093
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7472
Practice Address - Country:US
Practice Address - Phone:949-584-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist