Healthcare Provider Details

I. General information

NPI: 1366283749
Provider Name (Legal Business Name): TENNILLE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2024
Last Update Date: 06/01/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE F101
CHICAGO IL
60625-0035
US

IV. Provider business mailing address

5539 S PRAIRIE AVE APT B
CHICAGO IL
60637-1081
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-5809
  • Fax:
Mailing address:
  • Phone: 773-820-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.010608
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: