Provider Demographics
NPI:1699316877
Name:GLENN, TERRY
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 WYLIE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5405
Mailing Address - Country:US
Mailing Address - Phone:309-820-3744
Mailing Address - Fax:309-451-7761
Practice Address - Street 1:2148 VADALABENE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5632
Practice Address - Country:US
Practice Address - Phone:618-288-3100
Practice Address - Fax:618-288-3371
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.001987101Y00000X
IL178.011987101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional