Provider Demographics
NPI:1104170067
Name:WILLIAMS, CHENISE
Entity type:Individual
Prefix:MRS
First Name:CHENISE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2967
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32721-2967
Mailing Address - Country:US
Mailing Address - Phone:321-947-0706
Mailing Address - Fax:
Practice Address - Street 1:118 1/2 N WOODLAND BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-4268
Practice Address - Country:US
Practice Address - Phone:386-734-6355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007324200Medicaid