Healthcare Provider Details

I. General information

NPI: 1720394042
Provider Name (Legal Business Name): MRS. KERRY RAE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

738 S LONGMORE
MESA AZ
85202-1908
US

IV. Provider business mailing address

1025 N COUNTRY CLUB DR
MESA AZ
85201-3307
US

V. Phone/Fax

Practice location:
  • Phone: 480-472-4374
  • Fax: 480-472-4350
Mailing address:
  • Phone: 480-472-4374
  • Fax: 480-472-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: