Healthcare Provider Details

I. General information

NPI: 1871555292
Provider Name (Legal Business Name): GLENWILLOW PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12720 BENT OAK CT
INDIANAPOLIS IN
46236-7380
US

IV. Provider business mailing address

12720 BENT OAK CT
INDIANAPOLIS IN
46236-7380
US

V. Phone/Fax

Practice location:
  • Phone: 317-345-9687
  • Fax: 317-823-8645
Mailing address:
  • Phone: 317-345-9687
  • Fax: 317-823-8645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number05006252A
License Number StateIN

VIII. Authorized Official

Name: BETH E WATKINS
Title or Position: PRESIDENT
Credential:
Phone: 317-345-9687