Provider Demographics
NPI:1538623038
Name:PARTIN, GLEN DEAN (PTA)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:DEAN
Last Name:PARTIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 WOODHALL CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5757
Mailing Address - Country:US
Mailing Address - Phone:219-617-1832
Mailing Address - Fax:
Practice Address - Street 1:2620 W WALKER ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6812
Practice Address - Country:US
Practice Address - Phone:281-309-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2075653225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant