Healthcare Provider Details

I. General information

NPI: 1790961928
Provider Name (Legal Business Name): HEATHER D GLENN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MYRTLE ST
MOUNT VERNON WA
98273-3859
US

IV. Provider business mailing address

2790 BLUE MOUNTAIN RD
SEDRO WOOLLEY WA
98284-9688
US

V. Phone/Fax

Practice location:
  • Phone: 360-721-5320
  • Fax:
Mailing address:
  • Phone: 360-721-5320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00022972
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: