Basic Information
| Provider Information | |||||||||
| NPI: | 1376139576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUSTON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10827 | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323022827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505210242 | ||||||||
| FaxNumber: | 8505211973 | ||||||||
| Practice Location | |||||||||
| Address1: | 4820 KERRY FOREST PKWY | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323090200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505210242 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2020 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-147140 | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-20-147140 | 01 | RBT CERTIFICATION | OTHER |