Provider Demographics
NPI:1073013074
Name:WILLIAMS, GWENDOLYN VICTORIA
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:VICTORIA
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 1:24050 S PLUM VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-2647
Mailing Address - Country:US
Mailing Address - Phone:219-791-1006
Mailing Address - Fax:
Practice Address - Street 1:9111 BROADWAY STE N
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7097
Practice Address - Country:US
Practice Address - Phone:219-791-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker