Provider Demographics
NPI:1154190791
Name:WILLIAMS, TRINA
Entity type:Individual
Prefix:
First Name:TRINA
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 1:1223 RUDOLPH ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5713
Mailing Address - Country:US
Mailing Address - Phone:708-543-6867
Mailing Address - Fax:
Practice Address - Street 1:44 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4402
Practice Address - Country:US
Practice Address - Phone:708-543-6867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-23-314218106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician