Provider Demographics
NPI:1598097016
Name:WILLOWGLEN ACADEMY-IL, INC.
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY-IL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINARD
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:
Mailing Address - Fax:
Practice Address - Street 1:564 N GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-2943
Practice Address - Country:US
Practice Address - Phone:815-233-6162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CARE SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities