Provider Demographics
NPI:1104071125
Name:WEST LAKE RESIDENTIAL - BUILDING 220
Entity type:Organization
Organization Name:WEST LAKE RESIDENTIAL - BUILDING 220
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-588-2626
Mailing Address - Street 1:200 W LAKE DR BLDG 220
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-4956
Mailing Address - Country:US
Mailing Address - Phone:217-588-7934
Mailing Address - Fax:217-529-9803
Practice Address - Street 1:200 W LAKE DR
Practice Address - Street 2:BUILDING 220
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4956
Practice Address - Country:US
Practice Address - Phone:217-588-7934
Practice Address - Fax:217-529-9803
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MENTAL HEALTH CENTERS OF CENTRAL ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-18
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness