Provider Demographics
NPI:1174331474
Name:FRATICELLI, GLEN (CMT)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:FRATICELLI
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2643 SEMINOLE CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7872
Mailing Address - Country:US
Mailing Address - Phone:707-631-4841
Mailing Address - Fax:
Practice Address - Street 1:550 TRAVIS AVE BLDG 434
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-2108
Practice Address - Country:US
Practice Address - Phone:707-631-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98220225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty