Provider Demographics
NPI:1649337783
Name:WILLIAMS, SANDRA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 PHELPS AVE
Mailing Address - Street 2:SUITE 907
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2453
Mailing Address - Country:US
Mailing Address - Phone:815-227-0127
Mailing Address - Fax:815-227-0124
Practice Address - Street 1:129 PHELPS AVE
Practice Address - Street 2:SUITE 907
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2453
Practice Address - Country:US
Practice Address - Phone:815-227-0127
Practice Address - Fax:815-227-0124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0018181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR90574Medicare UPIN
IL630330Medicare ID - Type Unspecified