Provider Demographics
NPI:1285762930
Name:WILLIAMS, ROSE THIGPEN (MA, LPA #1646)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:THIGPEN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MA, LPA #1646
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 786
Mailing Address - Street 2:219 EAST MAIN STREET
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-0786
Mailing Address - Country:US
Mailing Address - Phone:910-298-4994
Mailing Address - Fax:910-298-6320
Practice Address - Street 1:219 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-0786
Practice Address - Country:US
Practice Address - Phone:910-298-4994
Practice Address - Fax:910-298-6320
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPA 1646103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1389XOtherBLUE CROSS BLUE SHIEL
NC6107132Medicaid