Basic Information
| Provider Information | |||||||||
| NPI: | 1740752146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | MADISON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BRAZIL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478341703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126052889 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 LIBRARY BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461421567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178819923 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2018 | ||||||||
| LastUpdateDate: | 12/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.