Healthcare Provider Details

I. General information

NPI: 1467753624
Provider Name (Legal Business Name): NORTH SHORE BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E WISCONSIN AVE SUITE 108
LAKE FOREST IL
60045-1735
US

IV. Provider business mailing address

PO BOX 35
LIBERTYVILLE IL
60048-0035
US

V. Phone/Fax

Practice location:
  • Phone: 877-570-7970
  • Fax: 877-570-7970
Mailing address:
  • Phone: 877-570-7970
  • Fax: 877-570-7970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071007667
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007667
License Number StateIL

VIII. Authorized Official

Name: DR. CAREY JEANNE WOODRUFF
Title or Position: DIRECTOR
Credential: PHD
Phone: 877-570-7970