Healthcare Provider Details

I. General information

NPI: 1487213278
Provider Name (Legal Business Name): MARK WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 MAIN ST W STE 20B
SNELLVILLE GA
30078-3073
US

IV. Provider business mailing address

3345 GOLFE LINKS DR
SNELLVILLE GA
30039-4728
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-7836
  • Fax:
Mailing address:
  • Phone: 770-377-8767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: