=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003615907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA LATRICE WILLIAMS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2025
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 DOUGLAS ST STE 500
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27705-6616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-358-4983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1295 BANDANA BLVD WEST STE 210
-----------------------------------------------------
City | ST. PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P021324
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------