Healthcare Provider Details

I. General information

NPI: 1679138622
Provider Name (Legal Business Name): LINDSEY RAE WILLIAMS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LINDSEY RAE BLAKLEY

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 E STATE ST
ROCKFORD IL
61108-2272
US

IV. Provider business mailing address

4920 E STATE ST
ROCKFORD IL
61108-2272
US

V. Phone/Fax

Practice location:
  • Phone: 608-280-2095
  • Fax: 815-256-0743
Mailing address:
  • Phone: 815-227-9002
  • Fax: 608-256-0743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011329
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: