=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295384774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALANA GLICKMAN MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2019
-----------------------------------------------------
Last Update Date | 09/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 N WELLS ST UNIT 103
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-6006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-702-5245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2601 BOB O LINK LN
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-702-5245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 242.005631
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------