Provider Demographics
NPI:1871555292
Name:GLENWILLOW PHYSICAL THERAPY
Entity type:Organization
Organization Name:GLENWILLOW PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-345-9687
Mailing Address - Street 1:12720 BENT OAK CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-7380
Mailing Address - Country:US
Mailing Address - Phone:317-345-9687
Mailing Address - Fax:317-823-8645
Practice Address - Street 1:12720 BENT OAK CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-7380
Practice Address - Country:US
Practice Address - Phone:317-345-9687
Practice Address - Fax:317-823-8645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006252A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000377434OtherANTHEM BCBS