=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851288054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TMJ PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2025
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 WOODSTOCK RD STE 310
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30075-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-868-7994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 930 WOODSTOCK RD STE 310
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30075-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-868-7994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. BRENDAN THOMAS GLACKIN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 404-868-7994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------