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1761 N Dilleys Rd Ste 210 Gurnee IL 60031-1721 | |
| (224) 419-5053 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 1761 N Dilleys Rd Ste 210, Gurnee, Illinois |
| Authorized Official Name and Position | Glenisha L.c. Foreman (OWNER) |
| Authorized Official Contact | 2246376999 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1761 N Dilleys Rd Ste 210 Gurnee IL 60031-1721 Ph: (224) 419-5053 | 1761 N Dilleys Rd Ste 210 Gurnee IL 60031-1721 Ph: (224) 419-5053 |
| NPI Number | 1619622685 |
|---|---|
| Provider Enumeration Date | 02/17/2022 |
| Last Update Date | 05/07/2024 |
| Certification Date | 05/07/2024 |
| Medicare PECOS PAC ID | 9436692571 |
|---|---|
| Medicare Enrollment ID | O20240618002113 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619622685 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Glenisha Lavene Cole Foreman |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1467062356 PECOS PAC ID: 0345783486 Enrollment ID: I20240618002210 |
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