=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154134682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LAMBS FARM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2025
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14245 W ROCKLAND RD
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-9745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-990-3833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14245 W ROCKLAND RD
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-9745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-990-3833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF PROGRAM OFFICER
-----------------------------------------------------
Name | MICHAEL DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-990-3833
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------