Healthcare Provider Details

I. General information

NPI: 1154339349
Provider Name (Legal Business Name): WILLIAM R TENNILL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 N WESTGATE AVE
JACKSONVILLE IL
62650-1156
US

IV. Provider business mailing address

800 E CARPENTER ST PO BOX 1977
SPRINGFIELD IL
62702-5324
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-7275
  • Fax: 217-245-7427
Mailing address:
  • Phone: 217-544-6464
  • Fax: 217-757-6021

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: