Provider Demographics
NPI:1720061773
Name:MULE-GLASS, VENISE (PT)
Entity type:Individual
Prefix:
First Name:VENISE
Middle Name:
Last Name:MULE-GLASS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3401
Mailing Address - Country:US
Mailing Address - Phone:631-499-1038
Mailing Address - Fax:631-499-2293
Practice Address - Street 1:297 COMMACK RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3401
Practice Address - Country:US
Practice Address - Phone:631-499-1038
Practice Address - Fax:631-499-2293
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5744-1225100000X, 2251N0400X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ52822Medicare ID - Type UnspecifiedMEDICARE