Provider Demographics
NPI:1992477798
Name:GLAZE, DAWN MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:GLAZE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:LAYTART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:9390 STATE ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45830-9609
Mailing Address - Country:US
Mailing Address - Phone:419-203-6494
Mailing Address - Fax:
Practice Address - Street 1:1036 S PERRY ST
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-2159
Practice Address - Country:US
Practice Address - Phone:419-592-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant