Healthcare Provider Details

I. General information

NPI: 1063035145
Provider Name (Legal Business Name): TERRENCE WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 SOUTHWICK DR STE 300
MATTESON IL
60443-2279
US

IV. Provider business mailing address

11422 S CHAMPLAIN AVE
CHICAGO IL
60628-4763
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-2655
  • Fax:
Mailing address:
  • Phone: 312-200-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: