Glen Allen Chilstrom, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

0810001353 Issued in VA

Practice address

109 S Fairfax St
Alexandria, VA 22314-3301

Phone

(703) 765-6085

NPI assigned

Jan 10, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in DC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 1985

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1136851200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1328572800000",
    "number": "1326027293",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1136 WESTMORELAND RD",
            "city": "ALEXANDRIA",
            "state": "VA",
            "postal_code": "223081245",
            "telephone_number": "703-765-6085"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 S FAIRFAX ST",
            "city": "ALEXANDRIA",
            "state": "VA",
            "postal_code": "223143301",
            "telephone_number": "703-765-6085"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CHILSTROM",
        "first_name": "GLEN",
        "middle_name": "ALLEN",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-01-10",
        "last_updated": "2012-02-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "VA",
            "license": "0810001353",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7701691",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Alexandria, VA
• Providers in Alexandria, VA by specialty
• Clinical Psychologist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 7, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.