Provider Demographics
NPI:1871372755
Name:GLENN, ASSAN
Entity type:Individual
Prefix:
First Name:ASSAN
Middle Name:
Last Name:GLENN
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 1:51 WATERMAN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06607-1537
Mailing Address - Country:US
Mailing Address - Phone:203-829-2566
Mailing Address - Fax:
Practice Address - Street 1:51 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06607-1537
Practice Address - Country:US
Practice Address - Phone:203-829-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1231009752225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation