MEDICARE: KIMBERLY WILLIAMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1003657768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY WILLIAMS

Provider Business Mailing Address
First Line	:	3239 GUADALOUPE
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6708
Country	:	US
Telephone Number	:	682-521-7428
Fax Number	:

Provider Business Practice Location Address
First Line	:	3239 GUADALOUPE
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6708
Country	:	US
Telephone Number	:	682-521-7428
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2024
Last Update Date	:	06/05/2024

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Directions to “ KIMBERLY WILLIAMS ” Practice Location

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