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General NPI Number Information
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NPI Number | 1417243288
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Entity Type | Organization
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Legal Business Name | COUNTY OF LAKE
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Dates
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Enumeration Date | 06/21/2011
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Last Update Date | 06/21/2011
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Provider Practice Location Address
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Address Line | 24647 N MILWAUKEE AVE
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City | VERNON HILLS
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State | IL
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Zip | 60061-1576
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Country | US
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Telephone | 847-377-7920
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Fax |
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Provider Business Mailing Address
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Address Line | 215 W WATER ST
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City | WAUKEGAN
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State | IL
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Zip | 60085-5616
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Country | US
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Telephone | 847-377-3675
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF PSYCHOLOGICAL SERVICES
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Name | DR. DENA TRAYLOR
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Credential | PSY.D.
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Telephone | 847-377-3675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 071.006552
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License Number State | IL
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