Provider Demographics
NPI:1649320847
Name:FAMILY SERVICE OF LAKE COUNTY
Entity type:Organization
Organization Name:FAMILY SERVICE OF LAKE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL CARE COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-432-4981
Mailing Address - Street 1:777 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3240
Mailing Address - Country:US
Mailing Address - Phone:847-432-4981
Mailing Address - Fax:847-432-7331
Practice Address - Street 1:777 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-432-4981
Practice Address - Fax:847-432-7331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004915366OtherBLUE CROSS BLUE SHIELD
IL0004915366OtherBLUE CROSS BLUE SHIELD
IL950350Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER HP