Provider Demographics
NPI:1336589837
Name:EASTERLING, GLENN CLARK JR (MA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:CLARK
Last Name:EASTERLING
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:OREANA
Mailing Address - State:IL
Mailing Address - Zip Code:62554-1975
Mailing Address - Country:US
Mailing Address - Phone:217-412-5023
Mailing Address - Fax:
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3929
Practice Address - Country:US
Practice Address - Phone:217-693-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008933101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional