Provider Demographics
NPI:1215242375
Name:PATRICK, GLENN S (PT)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:S
Last Name:PATRICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 VALLEY DR STE 2
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5203
Mailing Address - Country:US
Mailing Address - Phone:203-302-3570
Mailing Address - Fax:
Practice Address - Street 1:25 VALLEY DR STE 2
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5203
Practice Address - Country:US
Practice Address - Phone:203-302-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006406225100000X
NY62016632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist