Provider Demographics
NPI:1104271162
Name:GLEN LAKE PSYCHOLOGICAL SERVICES, LTD
Entity type:Organization
Organization Name:GLEN LAKE PSYCHOLOGICAL SERVICES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:FRUEHLING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-670-0880
Mailing Address - Street 1:1701 E LAKE AVE
Mailing Address - Street 2:SUITE #370
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2065
Mailing Address - Country:US
Mailing Address - Phone:847-657-9600
Mailing Address - Fax:847-998-8042
Practice Address - Street 1:1701 E LAKE AVE
Practice Address - Street 2:SUITE #370
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2065
Practice Address - Country:US
Practice Address - Phone:847-657-9600
Practice Address - Fax:847-998-8042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071001664103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty