Healthcare Provider Details

I. General information

NPI: 1003318395
Provider Name (Legal Business Name): GLASENHARDT AV, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5015 N PAULINA ST STE 214
CHICAGO IL
60640-2756
US

IV. Provider business mailing address

5015 N PAULINA ST STE 214
CHICAGO IL
60640-2756
US

V. Phone/Fax

Practice location:
  • Phone: 847-769-3948
  • Fax:
Mailing address:
  • Phone: 773-805-3534
  • Fax: 773-285-6333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147001288
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number147001288
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number147001288
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number147001288
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANA M GLASENHARDT
Title or Position: PRESIDENT
Credential: AUD
Phone: 773-805-3534