Healthcare Provider Details

I. General information

NPI: 1194820563
Provider Name (Legal Business Name): MEMORY BROOKE WILLIAMS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/27/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074A ROAD 1205
NETTLETON MS
38858-9714
US

IV. Provider business mailing address

1074A ROAD 1205
NETTLETON MS
38858-9714
US

V. Phone/Fax

Practice location:
  • Phone: 662-231-8788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1808
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: