Provider Demographics
NPI:1063035145
Name:WILLIAMS, TERRENCE
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11422 S CHAMPLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4763
Mailing Address - Country:US
Mailing Address - Phone:312-200-2060
Mailing Address - Fax:
Practice Address - Street 1:4801 SOUTHWICK DR STE 300
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2279
Practice Address - Country:US
Practice Address - Phone:708-747-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health