Healthcare Provider Details

I. General information

NPI: 1184635369
Provider Name (Legal Business Name): JONATHAN C GLENNEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SAYBROOK RD
MIDDLETOWN CT
06457-4777
US

IV. Provider business mailing address

410 SAYBROOK RD
MIDDLETOWN CT
06457-4777
US

V. Phone/Fax

Practice location:
  • Phone: 860-638-3820
  • Fax: 860-638-3824
Mailing address:
  • Phone: 860-638-3820
  • Fax: 860-638-3824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number006094
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number006094
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number006094
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006094
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: