Basic Information
| Provider Information | |||||||||
| NPI: | 1215441050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOWGLEN ACADEMY-ILLINOIS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W LAMM RD | ||||||||
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| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
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| Address1: | 701 W LAMM RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2017 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | KINARD | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8152625254 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
No ID Information.