Healthcare Provider Details

I. General information

NPI: 1639855216
Provider Name (Legal Business Name): KENYATTA WILLIAMS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14604 JOHN HUMPHREY DR STE 8
ORLAND PARK IL
60462-2642
US

IV. Provider business mailing address

4751 E 26TH AVE
LAKE STATION IN
46405-2635
US

V. Phone/Fax

Practice location:
  • Phone: 424-527-1873
  • Fax:
Mailing address:
  • Phone: 424-527-1873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: