Provider Demographics
NPI:1518510205
Name:WILLIAMS-WOLFORD, PENNY (MS, MSW, LSW)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:
Last Name:WILLIAMS-WOLFORD
Suffix:
Gender:F
Credentials:MS, MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 S 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3819
Mailing Address - Country:US
Mailing Address - Phone:708-705-0988
Mailing Address - Fax:
Practice Address - Street 1:2320 S 23RD AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3819
Practice Address - Country:US
Practice Address - Phone:708-705-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150101924104100000X
IL8540351041S0200X
IL24227051041S0200X
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool