Healthcare Provider Details

I. General information

NPI: 1821275017
Provider Name (Legal Business Name): NICOLE ELIZABETH GLIDDEN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ELIZABETH GLEASON

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 HUNTERS WAY
NORTH YARMOUTH ME
04097-6761
US

IV. Provider business mailing address

245 GORHAM RD
SCARBOROUGH ME
04074-9558
US

V. Phone/Fax

Practice location:
  • Phone: 901-692-3395
  • Fax:
Mailing address:
  • Phone: 901-692-3395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7682
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3372
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: