Healthcare Provider Details

I. General information

NPI: 1962446864
Provider Name (Legal Business Name): GLEN W ROWELL PT MA OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 WILLIS AVE
WILLISTON PARK NY
11596
US

IV. Provider business mailing address

397 WILLIS AVE
WILLISTON PARK NY
11596
US

V. Phone/Fax

Practice location:
  • Phone: 516-739-5503
  • Fax: 516-739-5565
Mailing address:
  • Phone: 516-739-5503
  • Fax: 516-739-5565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number013160
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: