Individual
MR. GLENN PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
871 OLD ALICE RD, SUITE 600, BROWNSVILLE, TX 78520-8268
(615) 714-8177
Mailing address
871 OLD ALICE RD, SUITE 600, BROWNSVILLE, TX 78520-8268
(615) 714-8177
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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