MEDICARE: MRS. LISA W. GLENN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	190058	TX

General Provider Information

NPI Number	:	1144592452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA W. GLENN

Provider Business Mailing Address
First Line	:	12522 MOSSYCUP DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-4937
Country	:	US
Telephone Number	:	713-973-8251
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 ENCLAVE PKWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-3671
Country	:	US
Telephone Number	:	281-920-0573
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2012
Last Update Date	:	02/01/2012

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