Healthcare Provider Details

I. General information

NPI: 1821210733
Provider Name (Legal Business Name): LAKE COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E GRAND AVE STE B
LAKE VILLA IL
60046-7829
US

IV. Provider business mailing address

3010 GRAND AVENUE
WAUKEGAN IL
60085-2321
US

V. Phone/Fax

Practice location:
  • Phone: 847-377-8280
  • Fax:
Mailing address:
  • Phone: 847-377-8180
  • Fax: 847-336-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: IRENE T PIERCE
Title or Position: EXECUTIVE DIRECTOR
Credential: MSN
Phone: 847-377-8000