=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144041021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FIRST CENTER OF LAKE COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2504 WASHINGTON ST STE 603
-----------------------------------------------------
City | WAUKEGAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60085-4984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-421-0948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2504 WASHINGTON ST STE 603
-----------------------------------------------------
City | WAUKEGAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60085-4984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-421-0948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. RACHEL CHENIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 224-421-0948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------