Provider Demographics
NPI:1881915270
Name:SAMPLE, GLENN (PSYD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 N ALPINE RD STE 104-609
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1462
Mailing Address - Country:US
Mailing Address - Phone:773-245-3449
Mailing Address - Fax:
Practice Address - Street 1:1643 N ALPINE RD STE 104-609
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1462
Practice Address - Country:US
Practice Address - Phone:773-245-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-20
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178010086101YP2500X
IL180010078101YP2500X
CA30340103TC0700X
IL071009666103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional