=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801723820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE HARBOR BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2026
-----------------------------------------------------
Last Update Date | 05/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3915 W OGLESBY AVE
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-404-7642
-----------------------------------------------------
Fax | 772-303-3434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3915 W OGLESBY AVE
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-404-7642
-----------------------------------------------------
Fax | 772-303-3434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF BILLING
-----------------------------------------------------
Name | CHRISTOPHER HALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-240-6190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------