Provider Demographics
NPI:1932288289
Name:GLAZESKI, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GLAZESKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 N WILLOW LAKE CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8260
Mailing Address - Country:US
Mailing Address - Phone:309-683-7373
Mailing Address - Fax:309-691-4408
Practice Address - Street 1:7317 N WILLOW LAKE CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8260
Practice Address - Country:US
Practice Address - Phone:309-683-7373
Practice Address - Fax:309-691-4408
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL680008174 - CA4079Medicare ID - Type UnspecifiedRR
IL541390Medicare ID - Type UnspecifiedGROUP #
ILR17724Medicare UPIN
IL751991Medicare ID - Type UnspecifiedHOSPITAL INDIVIDUAL
ILL70420Medicare ID - Type UnspecifiedINDIVIDUAL #