Basic Information
| Provider Information | |||||||||
| NPI: | 1144310509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2081 CALISTOGA DR | ||||||||
| Address2: | SUITE 2S | ||||||||
| City: | NEW LENOX | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604514831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154186070 | ||||||||
| FaxNumber: | 7798033119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2081 CALISTOGA DR | ||||||||
| Address2: | SUITE 2S | ||||||||
| City: | NEW LENOX | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604514831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154186070 | ||||||||
| FaxNumber: | 7798033119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036100519 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 036100519 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036100519 | 05 | IL | MEDICAID |