Healthcare Provider Details

I. General information

NPI: 1992973143
Provider Name (Legal Business Name): MICHELLE ELIZABETH WILLIAMS O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SOUTHPARK BLVD STE 202
SAINT AUGUSTINE FL
32086-5179
US

IV. Provider business mailing address

2005 MARIPOSA VISTA LN APT 207
SAINT AUGUSTINE FL
32084-0682
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-3103
  • Fax: 904-467-3422
Mailing address:
  • Phone: 215-805-1307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT20773
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 4671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: