Provider Demographics
NPI:1467062356
Name:FOREMAN, GLENISHA LAVENE COLE (MA, LCPC, NCC, CCTP)
Entity Type:Individual
Prefix:
First Name:GLENISHA
Middle Name:LAVENE COLE
Last Name:FOREMAN
Suffix:
Gender:F
Credentials:MA, LCPC, NCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 RED CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-8627
Mailing Address - Country:US
Mailing Address - Phone:224-703-4025
Mailing Address - Fax:
Practice Address - Street 1:1860 W WINCHESTER RD STE 205
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5317
Practice Address - Country:US
Practice Address - Phone:224-424-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015753101YM0800X
IL180.014284101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health