Provider Demographics
NPI:1871531863
Name:STACKHOUSE, GLENN ALAN (PT)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ALAN
Last Name:STACKHOUSE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07885-2020
Mailing Address - Country:US
Mailing Address - Phone:973-442-7937
Mailing Address - Fax:
Practice Address - Street 1:600 MOUNT PLEASANT AVE
Practice Address - Street 2:SUITE F
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-1629
Practice Address - Country:US
Practice Address - Phone:973-366-4000
Practice Address - Fax:973-366-4998
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00623700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist