Provider Demographics
NPI:1538683396
Name:WILLIAMS-ROSS, KENYATTA NICHOLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KENYATTA
Middle Name:NICHOLE
Last Name:WILLIAMS-ROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KENYATTA
Other - Middle Name:NICHOLE
Other - Last Name:WILLIAMS-ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2804 W JEROME ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1231
Mailing Address - Country:US
Mailing Address - Phone:630-701-5638
Mailing Address - Fax:
Practice Address - Street 1:355 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3328
Practice Address - Country:US
Practice Address - Phone:847-316-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490194501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical