Individual
DR. GLENN SAMPLE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSY.D.
Contact information
Practice address
1643 N ALPINE RD STE 104-609, ROCKFORD, IL 61107-1462
(773) 245-3449
Mailing address
1643 N ALPINE RD STE 104-609, ROCKFORD, IL 61107-1462
(773) 245-3449
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
178010086
IL
101YP2500X
Professional Counselor
180010078
IL
103TC0700X
Clinical Psychologist
Primary
071009666
IL
103TC0700X
Clinical Psychologist
30340
CA
Other
Enumeration date
06/20/2010
Last updated
03/08/2026
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