Healthcare Provider Details

I. General information

NPI: 1053258442
Provider Name (Legal Business Name): TANIKA LA-SHA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 30TH AVE
GULFPORT MS
39501-2741
US

IV. Provider business mailing address

1601 30TH AVE
GULFPORT MS
39501-2741
US

V. Phone/Fax

Practice location:
  • Phone: 228-284-2644
  • Fax: 855-402-2013
Mailing address:
  • Phone: 228-284-2644
  • Fax: 855-402-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC11904
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: