MEDICARE: COUNTY OF LAKE

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1659583920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF LAKE

Provider Business Mailing Address
First Line	:	3010 GRAND AVE.
Second Line	:
City	:	WAUKEGAN
State	:	IL
Zip	:	60085
Country	:	US
Telephone Number	:	847-377-8180
Fax Number	:	847-336-1517

Provider Business Practice Location Address
First Line	:	4118 GREENLEAF CT
Second Line	:
City	:	PARK CITY
State	:	IL
Zip	:	60085-8509
Country	:	US
Telephone Number	:	847-377-8170
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	ANGELA COOPER
Credential	:
Telephone Number	:	847-377-8000

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	09/10/2024

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Directions to “COUNTY OF LAKE ” Practice Location

Language	Start Address	Practice Location

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