Provider Demographics
NPI:1235665407
Name:GLASS, LAUREN ROSE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ROSE
Last Name:GLASS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 W CULLOM AVE #2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618
Mailing Address - Country:US
Mailing Address - Phone:312-208-3694
Mailing Address - Fax:
Practice Address - Street 1:3116 W CULLOM AVE # 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1304
Practice Address - Country:US
Practice Address - Phone:312-208-3694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009010235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist