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General NPI Number Information
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NPI Number | 1881915270
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Entity Type | Individual
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Provider Name | GLENN SAMPLE PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 06/20/2010
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Last Update Date | 08/04/2021
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Provider Practice Location Address
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Address Line | 1643 N ALPINE RD STE 104-609
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City | ROCKFORD
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State | IL
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Zip | 61107-1462
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Country | US
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Telephone | 773-245-3449
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Fax |
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Provider Business Mailing Address
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Address Line | 1643 N ALPINE RD STE 104-609
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City | ROCKFORD
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State | IL
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Zip | 61107-1462
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Country | US
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Telephone | 773-245-3449
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178010086
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180010078
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 30340
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071009666
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License Number State | IL
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