Provider Demographics
NPI:1306901756
Name:LIBMAN, GLENN MARK (PT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:MARK
Last Name:LIBMAN
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 1:12449 83RD PL NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2570
Mailing Address - Country:US
Mailing Address - Phone:425-820-2810
Mailing Address - Fax:
Practice Address - Street 1:12449 83RD PL NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2570
Practice Address - Country:US
Practice Address - Phone:425-820-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7490OtherPHYSICAL THERAPY LICENSE