Healthcare Provider Details

I. General information

NPI: 1952808610
Provider Name (Legal Business Name): MS. SONYA DELAINE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 RING RD
CALUMET CITY IL
60409-5459
US

IV. Provider business mailing address

22710 LAWNDALE AVE
RICHTON PARK IL
60471-2539
US

V. Phone/Fax

Practice location:
  • Phone: 708-862-8156
  • Fax:
Mailing address:
  • Phone: 170-857-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178013816
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: