Provider Demographics
NPI:1073788113
Name:WILLOWGLEN ACADEMY - INDIANA
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY - INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MUELLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:219-886-1320
Mailing Address - Street 1:308 E 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-2618
Mailing Address - Country:US
Mailing Address - Phone:219-886-1320
Mailing Address - Fax:
Practice Address - Street 1:308 E 21ST AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407-2618
Practice Address - Country:US
Practice Address - Phone:219-886-1320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHONENIX CARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-29
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33456322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children