MEDICARE: WILLOWGLEN ACADEMY-IL

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
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	411197-03	IL

General Provider Information

NPI Number	:	1386848299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOWGLEN ACADEMY-IL

Provider Business Mailing Address
First Line	:	701 W LAMM RD
Second Line	:
City	:	FREEPORT
State	:	IL
Zip	:	61032-9630
Country	:	US
Telephone Number	:	815-233-6162
Fax Number	:	815-233-6167

Provider Business Practice Location Address
First Line	:	3111 W KUNKLE BLVD
Second Line	:
City	:	FREEPORT
State	:	IL
Zip	:	61032-6922
Country	:	US
Telephone Number	:	815-233-0406
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. ELIZABETH A KINARD
Credential	:
Telephone Number	:	815-233-6162

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	08/22/2020

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Directions to “WILLOWGLEN ACADEMY-IL ” Practice Location

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