Provider Demographics
NPI:1760915227
Name:GLENN, KRISTIN (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 E WALNUT ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5002
Mailing Address - Country:US
Mailing Address - Phone:618-351-9700
Mailing Address - Fax:618-351-9701
Practice Address - Street 1:1257 E WALNUT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5002
Practice Address - Country:US
Practice Address - Phone:618-351-9700
Practice Address - Fax:618-351-9701
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178012387101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health