Provider Demographics
NPI:1174709810
Name:INDEPENDENCE CENTER, INC.
Entity type:Organization
Organization Name:INDEPENDENCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-360-1020
Mailing Address - Street 1:2025 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5131
Mailing Address - Country:US
Mailing Address - Phone:847-360-1020
Mailing Address - Fax:847-360-1065
Practice Address - Street 1:2025 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5131
Practice Address - Country:US
Practice Address - Phone:847-360-1020
Practice Address - Fax:847-360-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6331OtherMEDICARE PTAN
IL6331OtherMEDICARE PTAN