Provider Demographics
NPI:1962564971
Name:GITTERMAN, GLEN THOMAS (MS, PT, RKT, CSCS)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:THOMAS
Last Name:GITTERMAN
Suffix:
Gender:M
Credentials:MS, PT, RKT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 DEXTER AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6112
Mailing Address - Country:US
Mailing Address - Phone:203-237-9672
Mailing Address - Fax:
Practice Address - Street 1:2440 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3222
Practice Address - Country:US
Practice Address - Phone:203-230-1185
Practice Address - Fax:203-230-0776
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004343OtherPHYSICAL THERAPY LICENSE