=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609329952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL W GLAVIN LMFT & ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2016
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N WABASH AVE STE 1622
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-3038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-470-0788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N WABASH AVE STE 1722
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-2007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-470-0788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL W GLAVIN
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 312-672-1621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 166.000952
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------