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Crystal Lake, Illinois

Provider NPI: 1801895040

Provider Information:
Gender: F
Not Sole Proprietor

Practice Location:
Tel: 815-455-7100  Fax: 815-455-3951

Business Mailing Address:
Tel: 815-455-7100  Fax: 815-455-3951

Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y101Y00000XBehavioral Health & Social Service Providers

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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