Provider Demographics
NPI:1184721110
Name:WILLIAMS, LYDIA ANN (PHD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 LINCOLNSHIRE DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2189
Mailing Address - Country:US
Mailing Address - Phone:618-242-4205
Mailing Address - Fax:618-242-4209
Practice Address - Street 1:4230 LINCOLNSHIRE DR
Practice Address - Street 2:SUITE E
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2189
Practice Address - Country:US
Practice Address - Phone:618-242-4205
Practice Address - Fax:618-242-4209
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005322103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04132008OtherBCBS
IL04132008OtherBCBS