Provider Demographics
NPI:1043406044
Name:WILLEMSE, JOHANNA HERMINA (BA, MHP)
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:HERMINA
Last Name:WILLEMSE
Suffix:
Gender:F
Credentials:BA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3929
Mailing Address - Country:US
Mailing Address - Phone:217-373-2436
Mailing Address - Fax:
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3929
Practice Address - Country:US
Practice Address - Phone:217-373-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health