Provider Demographics
NPI:1043054364
Name:ANDERSON, GLENN DOUGLAS
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:DOUGLAS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37303 34TH AVE S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-8701
Mailing Address - Country:US
Mailing Address - Phone:253-592-9189
Mailing Address - Fax:
Practice Address - Street 1:909 S 336TH ST STE 100
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7394
Practice Address - Country:US
Practice Address - Phone:253-661-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160071875225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant