Provider Demographics
NPI:1609001189
Name:BARON, KELLY GLAZER (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:GLAZER
Last Name:BARON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 N LAKE SHORE DR
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3152
Mailing Address - Country:US
Mailing Address - Phone:312-503-5571
Mailing Address - Fax:312-503-2777
Practice Address - Street 1:710 N LAKE SHORE DR
Practice Address - Street 2:10TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3006
Practice Address - Country:US
Practice Address - Phone:312-503-5571
Practice Address - Fax:312-503-2777
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007561103TB0200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral