Provider Demographics
NPI:1265858013
Name:GLENN, MARIAN
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 S HIGHLAND AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5371
Mailing Address - Country:US
Mailing Address - Phone:630-261-1210
Mailing Address - Fax:
Practice Address - Street 1:2340 S HIGHLAND AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5371
Practice Address - Country:US
Practice Address - Phone:630-261-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011113363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health