Provider Demographics
NPI:1700268976
Name:GLICKMAN, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:GLICKMAN
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 1:1812 N WOLCOTT AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1004
Mailing Address - Country:US
Mailing Address - Phone:847-414-7203
Mailing Address - Fax:
Practice Address - Street 1:1812 N WOLCOTT AVE
Practice Address - Street 2:APT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1004
Practice Address - Country:US
Practice Address - Phone:847-414-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001252171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist