Healthcare Provider Details

I. General information

NPI: 1396735536
Provider Name (Legal Business Name): GLEN WARREN ROVIG MA, CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOONE RD
BREMERTON WA
98312-1894
US

IV. Provider business mailing address

1 BOONE RD
BREMERTON WA
98312-1894
US

V. Phone/Fax

Practice location:
  • Phone: 360-475-4214
  • Fax: 360-475-4214
Mailing address:
  • Phone: 360-475-4214
  • Fax: 360-475-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147.000470
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: