Healthcare Provider Details

I. General information

NPI: 1275686784
Provider Name (Legal Business Name): BERNARD GLOS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 OGDEN AVE LEGACY CLINICAL CONSULTANTS SUITE 210
LISLE IL
60532-1673
US

IV. Provider business mailing address

5703 S CASS AVE APT 213
WESTMONT IL
60559-3283
US

V. Phone/Fax

Practice location:
  • Phone: 630-527-1664
  • Fax:
Mailing address:
  • Phone: 603-963-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-003497
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: