Healthcare Provider Details

I. General information

NPI: 1144310509
Provider Name (Legal Business Name): JOHNNY LEE WILLIAMSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2081 CALISTOGA DR SUITE 2S
NEW LENOX IL
60451-4831
US

IV. Provider business mailing address

2081 CALISTOGA DR STE 2S
NEW LENOX IL
60451-4833
US

V. Phone/Fax

Practice location:
  • Phone: 815-418-6070
  • Fax: 779-803-3119
Mailing address:
  • Phone: 815-418-6070
  • Fax: 779-803-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2022-02652
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number169712
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036100519
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036100519
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number169712
License Number StateCA

VII. Legacy identifiers

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

# 1
Identifier036100519
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: