Healthcare Provider Details

I. General information

NPI: 1598037962
Provider Name (Legal Business Name): GLENN L JOHLMAN OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W LUGONIA AVE SUITE 240
REDLANDS CA
92374-9703
US

IV. Provider business mailing address

2 TENNESSEE ST APT B APT B
REDLANDS CA
92373-4482
US

V. Phone/Fax

Practice location:
  • Phone: 909-557-1600
  • Fax:
Mailing address:
  • Phone: 909-499-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT007046
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT11703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: