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Individual
MR. GLENN PETERSON
Active
Individual
MR. GLENN PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
2088488
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2088488
STATE LICENSE NUMBER
TX
Enumeration date
08/16/2012
Last updated
07/23/2013
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