Provider Demographics
NPI:1417227984
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:MS
Authorized Official - First Name:LORENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-886-1320
Mailing Address - Street 1:2301 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-3043
Mailing Address - Country:US
Mailing Address - Phone:219-886-2660
Mailing Address - Fax:219-886-1319
Practice Address - Street 1:2301 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407-3043
Practice Address - Country:US
Practice Address - Phone:219-886-2660
Practice Address - Fax:219-886-1319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CARE SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children