Healthcare Provider Details

I. General information

NPI: 1164002507
Provider Name (Legal Business Name): SHAMEKA DONIEDRE WILLIAMSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAMEKA DONIEDRE WILLIS

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 CALUMET PKWY BLDG J
NEWNAN GA
30263-6734
US

IV. Provider business mailing address

190 GENTLE DOE DR
FAYETTEVILLE GA
30214-8205
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-6946
  • Fax: 770-683-6949
Mailing address:
  • Phone: 318-547-1745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: