Healthcare Provider Details

I. General information

NPI: 1538380647
Provider Name (Legal Business Name): COUNTY OF LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 WILLOW LN APT C1
ZION IL
60099-1462
US

IV. Provider business mailing address

3010 GRAND AVE
WAUKEGAN IL
60085-2321
US

V. Phone/Fax

Practice location:
  • Phone: 847-377-8170
  • Fax: 847-782-6281
Mailing address:
  • Phone: 847-377-8000
  • Fax: 847-984-5761

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: SAM JOHNSON
Title or Position: DEPUTY EXECUTIVE DIRECTOR
Credential:
Phone: 847-377-8000