Provider Demographics
NPI:1063803500
Name:NOTSCH, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:NOTSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 E MEADOWBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4921
Mailing Address - Country:US
Mailing Address - Phone:602-369-6268
Mailing Address - Fax:
Practice Address - Street 1:2415 E MEADOWBROOK AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4921
Practice Address - Country:US
Practice Address - Phone:602-369-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9462APTA225200000X
COPTA0013022225200000X
MTPTP-PTA-LIC-5973225200000X
NMA-0901225200000X
WAP160320311225200000X
WY0799225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant