Healthcare Provider Details

I. General information

NPI: 1487858411
Provider Name (Legal Business Name): WILLOWGLEN ACADEMY - INDIANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E 21ST AVE
GARY IN
46407-2618
US

IV. Provider business mailing address

308 E 21ST AVE
GARY IN
46407-2618
US

V. Phone/Fax

Practice location:
  • Phone: 219-886-1320
  • Fax:
Mailing address:
  • Phone: 219-886-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number53769
License Number StateIN

VIII. Authorized Official

Name: MR. DWAYNE WARREN MUELLER
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 219-886-1320