=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780971671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN C WILLIAMS,PHD,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2011
-----------------------------------------------------
Last Update Date | 01/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2107 HENDRICKS AVE STE 2
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-3370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-716-0757
-----------------------------------------------------
Fax | 904-425-0028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2141 PARK ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32204-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-716-0757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | SUSAN CRAVEN WILLIAMS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 904-716-0757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY5815
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------