Provider Demographics
NPI:1063748119
Name:WILLIAMS, KYSHIA RENAE (MSW)
Entity type:Individual
Prefix:MRS
First Name:KYSHIA
Middle Name:RENAE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 UNIVERSITY BLVD S STE 403
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4986
Mailing Address - Country:US
Mailing Address - Phone:904-828-4003
Mailing Address - Fax:904-828-4395
Practice Address - Street 1:4251 UNIVERSITY BLVD S STE 403
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4986
Practice Address - Country:US
Practice Address - Phone:904-828-4003
Practice Address - Fax:904-828-4395
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003404400Medicaid