Healthcare Provider Details

I. General information

NPI: 1568413847
Provider Name (Legal Business Name): RYAN DOUGLAS GLOVER OTR/L, CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST STE 200
GRESHAM OR
97030-3373
US

IV. Provider business mailing address

PO BOX 2485
GRESHAM OR
97030-0660
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-1666
  • Fax: 503-491-1667
Mailing address:
  • Phone: 503-674-7860
  • Fax: 503-674-7642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1023386
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number1041100414
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: