Healthcare Provider Details

I. General information

NPI: 1235665407
Provider Name (Legal Business Name): LAUREN ROSE GLASS M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 W CULLOM AVE # 2
CHICAGO IL
60618-1304
US

IV. Provider business mailing address

3116 W CULLOM AVE #2
CHICAGO IL
60618
US

V. Phone/Fax

Practice location:
  • Phone: 312-208-3694
  • Fax:
Mailing address:
  • Phone: 312-208-3694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.009010
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: