Provider Demographics
NPI:1194849075
Name:CHAVEZ, GLENDA C (PT)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:C
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:R
Other - Last Name:CASILLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:428 N IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2329
Mailing Address - Country:US
Mailing Address - Phone:760-353-3422
Mailing Address - Fax:760-353-9163
Practice Address - Street 1:529 E ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-1930
Practice Address - Country:US
Practice Address - Phone:760-344-9000
Practice Address - Fax:760-344-9191
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 32601OtherPT LICENSE NUMBER
CAPT 32601OtherPT LICENSE NUMBER