Basic Information
| Provider Information | |||||||||
| NPI: | 1689656803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLAD | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900WW NORTH SHORE DR 160 | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472950340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 N WESTMORELAND RD | ||||||||
| Address2: | STE LL70 | ||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600451674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472950340 | ||||||||
| FaxNumber: | 8472950351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 07/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 071002465 | IL | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.