Organization
INDEPENDENCE CENTER, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LISA JOHNSON LCPC (EXECUTIVE DIRECTOR)
(847) 360-1020
Entity
Organization
Contact information
Practice address
2025 WASHINGTON ST, WAUKEGAN, IL 60085-5131
(847) 360-1020
(847) 360-1065
Mailing address
2025 WASHINGTON ST, WAUKEGAN, IL 60085-5131
(847) 360-1020
(847) 360-1065
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
Primary
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
IL6331
MEDICARE PTAN
—
Enumeration date
01/11/2008
Last updated
11/04/2016
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