1992893010 NPI number — WESTERN LAKE

Table of content: (NPI 1992893010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992893010 NPI number — WESTERN LAKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN LAKE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COUNSELING & DUI PROGRAMS LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992893010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 W GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOX LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60020-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-587-9700
Provider Business Mailing Address Fax Number:
847-587-8584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 W GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOX LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60020-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-587-9700
Provider Business Practice Location Address Fax Number:
847-587-8584
Provider Enumeration Date:
10/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HEDIEN
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
ROY
Authorized Official Title or Position:
DIRECTOR/ SOLE MBR OWNER
Authorized Official Telephone Number:
847-587-9700

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  A-1450-0002-A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A 1450 0002 A . This is a "DEPT OF HUMAN SERVICES OFFICE OF ALCOHOL & SUBSTANCE ABUSE (DHS/DASA)" identifier . This identifiers is of the category "OTHER".