Provider Demographics
NPI:1104336171
Name:GLASGOW, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:GLASGOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16338 N IL HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8178
Mailing Address - Country:US
Mailing Address - Phone:618-242-1510
Mailing Address - Fax:618-242-0950
Practice Address - Street 1:16338 N IL HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-8178
Practice Address - Country:US
Practice Address - Phone:618-242-1510
Practice Address - Fax:618-242-0950
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1649404708Medicaid