Healthcare Provider Details

I. General information

NPI: 1083663926
Provider Name (Legal Business Name): GLENN DAVID PRETTITORE MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 ROCK RD #236
GLEN ROCK NJ
07452-1708
US

IV. Provider business mailing address

233 ROCK RD #236
GLEN ROCK NJ
07452-1708
US

V. Phone/Fax

Practice location:
  • Phone: 201-345-7044
  • Fax: 201-345-7062
Mailing address:
  • Phone: 201-345-7044
  • Fax: 201-345-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA00989800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: