Provider Demographics
NPI:1922532332
Name:WILLIAMS, LA TANYA (LMT)
Entity Type:Individual
Prefix:
First Name:LA TANYA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NORTHGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-2663
Mailing Address - Country:US
Mailing Address - Phone:224-836-1160
Mailing Address - Fax:
Practice Address - Street 1:1275 E BALDWIN LN
Practice Address - Street 2:UNIT 308
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-3080
Practice Address - Country:US
Practice Address - Phone:708-674-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.018160225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist