Provider Demographics
NPI:1376212746
Name:WILLOWGLEN ACADEMY
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:KEDRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-709-0197
Mailing Address - Street 1:8521 SIX FORKS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5294
Mailing Address - Country:US
Mailing Address - Phone:919-709-0197
Mailing Address - Fax:
Practice Address - Street 1:201 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:IL
Practice Address - Zip Code:60112-4209
Practice Address - Country:US
Practice Address - Phone:815-758-8648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness