Basic Information
| Provider Information | |||||||||
| NPI: | 1467664730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE COUNTY BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778180 | ||||||||
| FaxNumber: | 8473361517 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 E GRAND AVE STE C | ||||||||
| Address2: | |||||||||
| City: | LAKE VILLA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600467829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473560055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | IRENE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8473778000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | IL | N | Agencies | Community/Behavioral Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.