Provider Demographics
NPI:1992893010
Name:WESTERN LAKE
Entity type:Organization
Organization Name:WESTERN LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ SOLE MBR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:HEDIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA NCC CADC
Authorized Official - Phone:847-587-9700
Mailing Address - Street 1:21 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1209
Mailing Address - Country:US
Mailing Address - Phone:847-587-9700
Mailing Address - Fax:847-587-8584
Practice Address - Street 1:21 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1209
Practice Address - Country:US
Practice Address - Phone:847-587-9700
Practice Address - Fax:847-587-8584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-1450-0002-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
A 1450 0002 AOtherDEPT OF HUMAN SERVICES OFFICE OF ALCOHOL & SUBSTANCE ABUSE (DHS/DASA)