Healthcare Provider Details

I. General information

NPI: 1609329952
Provider Name (Legal Business Name): MICHAEL W GLAVIN LMFT & ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N WABASH AVE STE 1622
CHICAGO IL
60602-3038
US

IV. Provider business mailing address

111 N WABASH AVE STE 1722
CHICAGO IL
60602-2007
US

V. Phone/Fax

Practice location:
  • Phone: 312-470-0788
  • Fax:
Mailing address:
  • Phone: 312-470-0788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.000952
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL W GLAVIN
Title or Position: PRESIDENT
Credential: LMFT
Phone: 312-672-1621