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NPI Code Detail

MEDICARE: INDEPENDENCE CENTER, INC.

MEDICARE: INDEPENDENCE CENTER, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251B00000XCase Management Agency
2320800000XMental Illness Community Based Residential Treatment Facility
3261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)
4261QM0850XAdult Mental Health Clinic/Center
5251S00000XCommunity/Behavioral Health Agency

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1IL6331OTHERMEDICARE PTAN

General Provider Information

NPI Number : 1174709810
Entity Type Code : Organization
Provider Name (Legal Business Name) : INDEPENDENCE CENTER, INC.
Provider Business Mailing Address
First Line : 2025 WASHINGTON ST
Second Line :
City : WAUKEGAN
State : IL
Zip : 60085-5131
Country : US
Telephone Number : 847-360-1020
Fax Number : 847-360-1065
Provider Business Practice Location Address
First Line : 2025 WASHINGTON ST
Second Line :
City : WAUKEGAN
State : IL
Zip : 60085-5131
Country : US
Telephone Number : 847-360-1020
Fax Number : 847-360-1065
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : MS. LISA JOHNSON
Credential : LCPC
Telephone Number : 847-360-1020
Provider Enumeration Date : 01/11/2008
Last Update Date : 11/04/2016

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1871881235 — MS. LISA MARILYN JOHNSON LCPC
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1689946030 — MRS. OUIDA BEARD
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Directions to “INDEPENDENCE CENTER, INC. ” Practice Location

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