=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952541948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EILEEN H GLENN MA LCPC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 03/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 RIDGE AVE SUITE 101B
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-5918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-733-9661
-----------------------------------------------------
Fax | 847-733-1571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2209 DODGE AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-733-1567
-----------------------------------------------------
Fax | 187-733-1571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EILEEN H GLENN
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 847-733-9661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180003470
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------