Healthcare Provider Details

I. General information

NPI: 1639359698
Provider Name (Legal Business Name): NINA M WILLIAMS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21317 S JEFFREY DR
MATTESON IL
60443-2467
US

IV. Provider business mailing address

203 WYSTERIA DR
OLYMPIA FIELDS IL
60461-1202
US

V. Phone/Fax

Practice location:
  • Phone: 363-944-5897
  • Fax:
Mailing address:
  • Phone: 336-944-5897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008569
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP006305
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021613
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149021613
License Number StateIL

VII. Legacy identifiers

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

# 1
Identifier6005168
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: