Healthcare Provider Details

I. General information

NPI: 1639097256
Provider Name (Legal Business Name): GLENN PHILIP LUTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 MONTGOMERY RD
ALTAMONTE SPRINGS FL
32714-6830
US

IV. Provider business mailing address

360 MONTGOMERY RD
ALTAMONTE SPRINGS FL
32714-6830
US

V. Phone/Fax

Practice location:
  • Phone: 407-335-4171
  • Fax:
Mailing address:
  • Phone: 407-335-4171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA13069
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: