Healthcare Provider Details

I. General information

NPI: 1235561069
Provider Name (Legal Business Name): THERESA WILLIAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 STONE ST
WILDWOOD FL
34785-3344
US

IV. Provider business mailing address

301 STONE ST
WILDWOOD FL
34785-3344
US

V. Phone/Fax

Practice location:
  • Phone: 352-748-7032
  • Fax: 352-748-7032
Mailing address:
  • Phone: 352-748-7032
  • Fax: 352-748-7032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberWER1234
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. THERESA L WILLIAMS
Title or Position: LPN
Credential:
Phone: 352-748-7032