Provider Demographics
NPI:1619337060
Name:WILLIAMS, CAMILLE
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:
Other - Last Name:MALECHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6685 DOUBLE EAGLE DR
Mailing Address - Street 2:APT 212
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-5419
Mailing Address - Country:US
Mailing Address - Phone:224-715-4953
Mailing Address - Fax:
Practice Address - Street 1:214 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-2449
Practice Address - Country:US
Practice Address - Phone:847-854-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-27
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009923101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional