Provider Demographics
NPI:1356634174
Name:WILLOWGLEN ACADEMY IL
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY IL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-233-6162
Mailing Address - Street 1:701 W LAMM RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9630
Mailing Address - Country:US
Mailing Address - Phone:815-233-6162
Mailing Address - Fax:
Practice Address - Street 1:701 W LAMM RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9630
Practice Address - Country:US
Practice Address - Phone:815-233-6162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management