Provider Demographics
NPI:1356672828
Name:GLESSNER, HEATHER L D (MS, CGC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L D
Last Name:GLESSNER
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19659
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9659
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-757-6388
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 6W30
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-6388
Is Sole Proprietor?:No
Enumeration Date:2010-01-23
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246-000086170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid