Healthcare Provider Details

I. General information

NPI: 1043033590
Provider Name (Legal Business Name): INNER GLOW COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BRADFORD LN STE C
WATERLOO IL
62298-3370
US

IV. Provider business mailing address

220 BRADFORD LN STE C
WATERLOO IL
62298-3370
US

V. Phone/Fax

Practice location:
  • Phone: 618-520-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KAITLYN PARKMAN
Title or Position: OWNER
Credential: LCPC
Phone: 618-520-4800