Basic Information
| Provider Information | |||||||||
| NPI: | 1386848299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOWGLEN ACADEMY-IL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W LAMM RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
| FaxNumber: | 8152336167 | ||||||||
| Practice Location | |||||||||
| Address1: | 3111 W KUNKLE BLVD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610326922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152330406 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KINARD | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8152336162 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 411197-03 | IL | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
No ID Information.