Provider Demographics
NPI:1366283749
Name:WILLIAMS, TENNILLE
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5539 S PRAIRIE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1081
Mailing Address - Country:US
Mailing Address - Phone:773-820-0182
Mailing Address - Fax:
Practice Address - Street 1:5215 N CALIFORNIA AVE STE F101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-0035
Practice Address - Country:US
Practice Address - Phone:773-561-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010608101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional