Healthcare Provider Details

I. General information

NPI: 1255378881
Provider Name (Legal Business Name): WILLIAM ELLSWORTH JOHNSON III MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVE AT ROOSEVELT RD. EDWARD HINES JR. VA HOSPITAL, BLDG 200 ROOM 610
HINES IL
60141-5122
US

IV. Provider business mailing address

209 S OAK PARK AVE APT. 402
OAK PARK IL
60302-3262
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2101
  • Fax: 708-202-2346
Mailing address:
  • Phone: 708-383-5032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: