Provider Demographics
NPI:1154601680
Name:WILLIAMS, MICHELLE THERESA
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:THERESA
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 1:1504 CROYDON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6848
Mailing Address - Country:US
Mailing Address - Phone:407-412-8438
Mailing Address - Fax:
Practice Address - Street 1:1504 CROYDON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6848
Practice Address - Country:US
Practice Address - Phone:407-412-8438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10511174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist