Provider Demographics
NPI:1649252495
Name:AYLWARD, GLEN P (PHD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:P
Last Name:AYLWARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19658
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9658
Mailing Address - Country:US
Mailing Address - Phone:217-545-2618
Mailing Address - Fax:217-545-5834
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-2618
Practice Address - Fax:217-545-5834
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002533103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$002Medicaid