Healthcare Provider Details

I. General information

NPI: 1588020556
Provider Name (Legal Business Name): GLYNN PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/02/2022
Certification Date: 01/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 BEDFORD ST STE 7
LEXINGTON MA
02420-4640
US

IV. Provider business mailing address

76 BEDFORD ST STE 7
LEXINGTON MA
02420-4640
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-0200
  • Fax: 781-862-0600
Mailing address:
  • Phone: 781-862-0200
  • Fax: 781-862-0600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number11353
License Number StateMA

VIII. Authorized Official

Name: PAUL EUGENE GLYNN
Title or Position: PRESIDENT/OWNER
Credential: PT
Phone: 781-862-0200