Provider Demographics
NPI:1548852072
Name:GLENKIRK
Entity type:Organization
Organization Name:GLENKIRK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPHA
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ZANON-TOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-272-5111
Mailing Address - Street 1:3504 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1821
Mailing Address - Country:US
Mailing Address - Phone:847-272-5111
Mailing Address - Fax:847-272-7350
Practice Address - Street 1:3504 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1821
Practice Address - Country:US
Practice Address - Phone:847-272-5111
Practice Address - Fax:847-272-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-05
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBHC-2121401Medicaid