Basic Information
| Provider Information | |||||||||
| NPI: | 1710159959 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOWGLEN ACADEMY | ||||||||
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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: | 701 W LAMM RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
| FaxNumber: | 8152336167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOOKS | ||||||||
| AuthorizedOfficialFirstName: | ABIGAIL | ||||||||
| AuthorizedOfficialMiddleName: | LYN | ||||||||
| AuthorizedOfficialTitleorPosition: | QMRP | ||||||||
| AuthorizedOfficialTelephone: | 8152336162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | IL | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.