Provider Demographics
NPI:1427768134
Name:GLAVICH, JONATHAN (OTR/L)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GLAVICH
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BARNINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-5505
Mailing Address - Country:US
Mailing Address - Phone:919-744-7852
Mailing Address - Fax:
Practice Address - Street 1:1221 BROAD ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-3602
Practice Address - Country:US
Practice Address - Phone:919-552-4580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15274225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist