Individual
DR. GLEN ALLEN CHILSTROM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
109 S FAIRFAX ST, ALEXANDRIA, VA 22314-3301
(703) 765-6085
Mailing address
1136 WESTMORELAND RD, ALEXANDRIA, VA 22308-1245
(703) 765-6085
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
0810001353
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7701691
—
VA
Enumeration date
01/10/2006
Last updated
02/07/2012
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