=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396640553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS LYDIA LENORA MIMS-WILLINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2026
-----------------------------------------------------
Last Update Date | 10/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16162 ELLIS AVE STE 1N
-----------------------------------------------------
City | SOUTH HOLLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60473-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-378-6480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15314 DIEKMAN CT
-----------------------------------------------------
City | DOLTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60419-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-378-6480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.131855
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------