Healthcare Provider Details

I. General information

NPI: 1609788629
Provider Name (Legal Business Name): NIKITA RAE WILLIAMSON M.S., SLP-CF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E BASELINE RD STE 124
MESA AZ
85206-4679
US

IV. Provider business mailing address

4824 E BASELINE RD STE 124
MESA AZ
85206-4679
US

V. Phone/Fax

Practice location:
  • Phone: 480-389-6749
  • Fax:
Mailing address:
  • Phone: 480-389-6749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberTSLP17931
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: