1700257581 NPI number — WILLOUGHBY CENTER FOR BEHAVIORAL HEALTH, LLC

Table of content: (NPI 1700257581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700257581 NPI number — WILLOUGHBY CENTER FOR BEHAVIORAL HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOUGHBY CENTER FOR BEHAVIORAL HEALTH, LLC
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:
Provider Other Organization Name Type Code:
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:
1700257581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1603 ORRINGTON AVE STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-3860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-585-3312
Provider Business Mailing Address Fax Number:
224-585-3619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1603 ORRINGTON AVE.
Provider Second Line Business Practice Location Address:
STE. 600
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-585-3312
Provider Business Practice Location Address Fax Number:
224-585-3619
Provider Enumeration Date:
10/19/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLOUGHBY
Authorized Official First Name:
CINDI-MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
773-814-1445

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071.008303 , 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: 558816518-001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487929345 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".