Provider Demographics
NPI:1740507821
Name:NORTHWEST TREATMENT ASSOCIATES
Entity type:Organization
Organization Name:NORTHWEST TREATMENT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FETZNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, NCC, LCPC
Authorized Official - Phone:815-337-1234
Mailing Address - Street 1:1185 DUNDEE AVE STE E1
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-2233
Mailing Address - Country:US
Mailing Address - Phone:847-608-8570
Mailing Address - Fax:847-608-8572
Practice Address - Street 1:1185 DUNDEE AVE STE E1
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2233
Practice Address - Country:US
Practice Address - Phone:847-608-8570
Practice Address - Fax:847-608-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000371251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health